Provider Demographics
NPI:1205909967
Name:EVONICH, RUDOLPH FRANCIS III (MD)
Entity type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:FRANCIS
Last Name:EVONICH
Suffix:III
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:920-433-3716
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21241-875207RC0001X
MI4301076776207RC0001X
WI77869-20207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00412659OtherRAILROAD MEDICARE
MI0605210971OtherBLUE CROSS BLUE SHIELD
MI5184312Medicaid
WI34966000Medicaid
P00412659OtherRAILROAD MEDICARE
WI34966000Medicaid