Provider Demographics
NPI:1558322214
Name:RUDMAN, KENNETH SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SAMUEL
Last Name:RUDMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 LAKE LANSING RD
Mailing Address - Street 2:SUITE G06
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3756
Mailing Address - Country:US
Mailing Address - Phone:517-482-7246
Mailing Address - Fax:517-484-7377
Practice Address - Street 1:1540 LAKE LANSING RD
Practice Address - Street 2:SUITE G06
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3756
Practice Address - Country:US
Practice Address - Phone:517-482-7246
Practice Address - Fax:517-484-7377
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049943207L00000X, 207LP2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2919118Medicaid
MI1984819Medicaid
MIOC36144001Medicare ID - Type UnspecifiedLAA MCR
MI1984819Medicaid
MIOC36404004Medicare ID - Type UnspecifiedMPMS MCR