Provider Demographics
NPI:1457362717
Name:RUDOLPH, RHYS (MD)
Entity Type:Individual
Prefix:
First Name:RHYS
Middle Name:
Last Name:RUDOLPH
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:1818 CAREW ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4788
Practice Address - Country:US
Practice Address - Phone:260-482-8681
Practice Address - Fax:260-373-4699
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029545208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100338370Medicaid
IN000000633802OtherANTHEM
INP00803483OtherR.R. MEDICARE
IN000000633802OtherANTHEM
IN048010 CMedicare PIN
IN264090EMedicare PIN
INP00803483OtherR.R. MEDICARE
IN100338370Medicaid