Provider Demographics
NPI:1669403754
Name:NICOLAS, RUDY J (MD)
Entity type:Individual
Prefix:
First Name:RUDY
Middle Name:J
Last Name:NICOLAS
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 1:611 UNIVERSITY DR
Mailing Address - Street 2:611 MRI
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-6552
Mailing Address - Country:US
Mailing Address - Phone:814-234-2600
Mailing Address - Fax:814-867-5285
Practice Address - Street 1:611 UNIVERSITY DR
Practice Address - Street 2:611 MRI
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-6552
Practice Address - Country:US
Practice Address - Phone:814-234-2600
Practice Address - Fax:814-867-5285
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA683230Medicaid
PAC31041Medicare UPIN
PA128226Medicare ID - Type Unspecified