Provider Demographics
NPI:1518079664
Name:GREGORY DAVID RUDOLF
Entity Type:Organization
Organization Name:GREGORY DAVID RUDOLF
Other - Org Name:GREGORY DAVID RUDOLF, MD PS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:RUDOLF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-386-2013
Mailing Address - Street 1:PO BOX 94546
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6846
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:
Practice Address - Street 1:1101 MADISON ST
Practice Address - Street 2:STE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1306
Practice Address - Country:US
Practice Address - Phone:206-386-2013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041809207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8809345Medicare ID - Type Unspecified