Provider Demographics
NPI:1770782062
Name:RUDICIL, SHAUN MICHAEL
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:MICHAEL
Last Name:RUDICIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FORT JESSE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6286
Mailing Address - Country:US
Mailing Address - Phone:309-454-1616
Mailing Address - Fax:309-454-5167
Practice Address - Street 1:3101 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-366-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant