Provider Demographics
NPI:1205885944
Name:RUDICK, DONALD HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:HENRY
Last Name:RUDICK
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 1:761 JOHNSONBURG RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ST MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-3483
Mailing Address - Country:US
Mailing Address - Phone:814-781-8669
Mailing Address - Fax:814-781-8671
Practice Address - Street 1:761 JOHNSONBURG RD
Practice Address - Street 2:SUITE 350
Practice Address - City:ST MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-3483
Practice Address - Country:US
Practice Address - Phone:814-781-8669
Practice Address - Fax:814-781-8671
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056864L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019212650001Medicaid
PA1444738OtherHIGHMARK PROVIDER NUMBER
PA060469Medicare ID - Type UnspecifiedPROVIDER NUMBER
PA0019212650001Medicaid