Provider Demographics
NPI:1922108927
Name:VERVAEKE, RUDY JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDY
Middle Name:JEROME
Last Name:VERVAEKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21420 HARPER AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3607
Mailing Address - Country:US
Mailing Address - Phone:586-775-7400
Mailing Address - Fax:586-775-0091
Practice Address - Street 1:21420 HARPER AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3607
Practice Address - Country:US
Practice Address - Phone:586-775-7400
Practice Address - Fax:586-775-0091
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044898207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4842512-10Medicaid
MI352263519OtherCOMMERCIAL
MA1105018171OtherBLUE CROSS BLUE SHIELD
MI0P26650Medicare ID - Type Unspecified
MIB47051Medicare UPIN