Provider Demographics
NPI:1508821463
Name:THELL, RUDY G (MD)
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:G
Last Name:THELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4001
Mailing Address - Country:US
Mailing Address - Phone:651-232-4800
Mailing Address - Fax:651-232-4899
Practice Address - Street 1:1390 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4001
Practice Address - Country:US
Practice Address - Phone:651-232-4800
Practice Address - Fax:651-232-4899
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN22039207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN862893900Medicaid
A95812Medicare UPIN
110005192Medicare ID - Type Unspecified