Provider Demographics
NPI:1790766988
Name:RUDY, RUSSELL M (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
Last Name:RUDY
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:PO BOX 713464
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-0001
Mailing Address - Country:US
Mailing Address - Phone:740-687-8990
Mailing Address - Fax:740-687-8230
Practice Address - Street 1:401 N EWING ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3372
Practice Address - Country:US
Practice Address - Phone:740-687-8000
Practice Address - Fax:740-687-8939
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35049204OtherOHIO STATE LICENSE NO
OH0683532Medicaid
OHRU7151181Medicare ID - Type UnspecifiedOHIO MEDICARE PROVIDER NO
OH0683532Medicaid