Provider Demographics
NPI:1710092259
Name:HAMAD, RUDOLPH (CAA)
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:
Last Name:HAMAD
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 SPENCERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3923
Mailing Address - Country:US
Mailing Address - Phone:202-299-6084
Mailing Address - Fax:
Practice Address - Street 1:5959 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1888
Practice Address - Country:US
Practice Address - Phone:419-897-5501
Practice Address - Fax:419-897-5502
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCAA000003367H00000X
OH67.000363367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCP00183258Medicare ID - Type UnspecifiedRAILROAD MEDICARE
DC015520W13Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH