Provider Demographics
NPI:1801810338
Name:RUDNICKI, MAREK (M D)
Entity type:Individual
Prefix:MR
First Name:MAREK
Middle Name:
Last Name:RUDNICKI
Suffix:
Gender:M
Credentials:M D
Other - Prefix:MRS
Other - First Name:BIANKA
Other - Middle Name:
Other - Last Name:NOBLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPC
Mailing Address - Street 1:3000 N HALSTED ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5190
Mailing Address - Country:US
Mailing Address - Phone:773-296-3838
Mailing Address - Fax:773-327-1718
Practice Address - Street 1:3000 N HALSTED ST
Practice Address - Street 2:SUITE 603
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5190
Practice Address - Country:US
Practice Address - Phone:773-296-3838
Practice Address - Fax:773-327-1718
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094616208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094616Medicaid
IL036094616Medicaid
701680Medicare ID - Type Unspecified