Provider Demographics
NPI:1922190917
Name:IDE, RUDI (RPT)
Entity Type:Individual
Prefix:MR
First Name:RUDI
Middle Name:
Last Name:IDE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NW 10TH AVE
Mailing Address - Street 2:#201
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1312
Mailing Address - Country:US
Mailing Address - Phone:561-338-6100
Mailing Address - Fax:561-338-6434
Practice Address - Street 1:1500 NW 10TH AVE
Practice Address - Street 2:#201
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1312
Practice Address - Country:US
Practice Address - Phone:561-338-6100
Practice Address - Fax:561-338-6434
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT005031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY2736OtherBCBS FL
FLE2622ZMedicare ID - Type UnspecifiedPHYSICAL THERAPY