Provider Demographics
NPI:1558564021
Name:CEDAR GROVE MEDICAL ASSOCIATES,LLC
Entity Type:Organization
Organization Name:CEDAR GROVE MEDICAL ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-459-6700
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:WEST PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42086-0520
Mailing Address - Country:US
Mailing Address - Phone:270-744-0404
Mailing Address - Fax:270-744-0606
Practice Address - Street 1:301 WOLVERINE TRAIL
Practice Address - Street 2:SUITE 100
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167
Practice Address - Country:US
Practice Address - Phone:615-459-6700
Practice Address - Fax:615-459-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000012820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31883142Medicare PIN