Provider Demographics
NPI:1295732923
Name:RUDOLPH, MICHAEL PATRICK (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DO
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 9168
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-9168
Mailing Address - Country:US
Mailing Address - Phone:866-825-8303
Mailing Address - Fax:866-582-7105
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-2142
Practice Address - Fax:605-622-5127
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3564207L00000X, 207LP2900X
IN02003014A207L00000X
WI35353207L00000X
TNDO0000001935207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0120733Medicaid
IA0442343Medicaid
IN000000391600OtherANTHEM PROVIDER NUMBER
IN200802530Medicaid
IN11507531OtherCAQH NUMBER
IN9265107OtherPHCS PID NUMBER
IA50171OtherWELLMARK GROUP #
SD4571OtherMEDICAL LICENSE
SD4571OtherMEDICAL LICENSE
IA50171Medicare ID - Type UnspecifiedMEDICARE GROUP #
IN200802530Medicaid
IN9265107OtherPHCS PID NUMBER
IN000000391600OtherANTHEM PROVIDER NUMBER
INP00365192Medicare PIN