Provider Demographics
NPI:1477652287
Name:RUDISEL, BRENT A (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:RUDISEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503A N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2443
Mailing Address - Country:US
Mailing Address - Phone:618-842-2491
Mailing Address - Fax:618-842-2497
Practice Address - Street 1:503A N 1ST ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2443
Practice Address - Country:US
Practice Address - Phone:618-842-2491
Practice Address - Fax:618-842-2497
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111757207P00000X
IN02002497A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH33508Medicare UPIN