Provider Demographics
NPI:1891728879
Name:GOSKE RUDICK, MARILYN J (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:GOSKE RUDICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:ML 5021
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3039
Mailing Address - Country:US
Mailing Address - Phone:513-636-2039
Mailing Address - Fax:866-851-6567
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:ML 5031
Practice Address - City:CINCINNATO
Practice Address - State:OH
Practice Address - Zip Code:45229-3039
Practice Address - Country:US
Practice Address - Phone:513-636-4251
Practice Address - Fax:513-636-8145
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0545872085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2625261Medicaid
OH2625261Medicaid
C49674Medicare UPIN