Provider Demographics
NPI:1003818634
Name:MENCHL, RUDOLPH JR (MD)
Entity type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:
Last Name:MENCHL
Suffix:JR
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 1:22201 MOROSS RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2169
Mailing Address - Country:US
Mailing Address - Phone:313-886-8787
Mailing Address - Fax:313-886-4103
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:SUITE 150
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:313-886-8787
Practice Address - Fax:313-886-4103
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIRM056156207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH 26358019Medicare ID - Type Unspecified
F27717Medicare UPIN