Provider Demographics
NPI:1891958054
Name:JERUDI, MAHER (MD)
Entity Type:Individual
Prefix:
First Name:MAHER
Middle Name:
Last Name:JERUDI
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 1:12981 - 50 STREET NW, UNIT 10
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T5A 3P3
Mailing Address - Country:CA
Mailing Address - Phone:709-589-5387
Mailing Address - Fax:
Practice Address - Street 1:12981 - 50 STREET NW, UNIT 10
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:ALBERTA
Practice Address - Zip Code:T5A 3P3
Practice Address - Country:CA
Practice Address - Phone:709-589-5387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY47516207R00000X
OH35.129578207R00000X
PAMD446923207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program