Provider Demographics
NPI:1578658118
Name:RUDELICH, JASON CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:CHARLES
Last Name:RUDELICH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 W. SILVER SPRING DR.
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-961-7100
Mailing Address - Fax:414-961-7772
Practice Address - Street 1:309 W. SILVER SPRING DR.
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-961-7100
Practice Address - Fax:414-961-7772
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3853-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIU91512Medicare UPIN