Provider Demographics
NPI:1790719664
Name:RUDNICK, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:RUDNICK
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 1:51 N 39TH ST
Mailing Address - Street 2:MOB SUITE 240
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-8730
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:MOB SUITE 240
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014337E207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000675069Medicaid
PA076180Medicare PIN
PAC29132Medicare UPIN