Provider Demographics
NPI:1578542999
Name:RUDOLPH, KENNETH H (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:RUDOLPH
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 1:802 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510
Mailing Address - Country:US
Mailing Address - Phone:570-343-3999
Mailing Address - Fax:570-343-2749
Practice Address - Street 1:802 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1038
Practice Address - Country:US
Practice Address - Phone:570-343-3999
Practice Address - Fax:570-343-2749
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021263E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000609340Medicaid
PA000609340Medicaid
PA124208Medicare PIN