Provider Demographics
NPI:1790797207
Name:RUDY, WILLIAM M (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
Last Name:RUDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1554
Mailing Address - Country:US
Mailing Address - Phone:248-541-2512
Mailing Address - Fax:
Practice Address - Street 1:2635 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1554
Practice Address - Country:US
Practice Address - Phone:248-541-2512
Practice Address - Fax:248-541-0232
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2832956Medicaid
MIE38212Medicare UPIN
MI2832956Medicaid