Provider Demographics
NPI:1841287109
Name:RUDDER, MICHIEL BRENT (FNP MSW)
Entity type:Individual
Prefix:
First Name:MICHIEL
Middle Name:BRENT
Last Name:RUDDER
Suffix:
Gender:M
Credentials:FNP MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11567
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0126
Mailing Address - Country:US
Mailing Address - Phone:731-661-0086
Mailing Address - Fax:731-661-9702
Practice Address - Street 1:622 WEST MARKET STREET
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008
Practice Address - Country:US
Practice Address - Phone:731-658-4500
Practice Address - Fax:731-658-4545
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN131561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3909409Medicaid
MR0784276OtherDEA
P40828Medicare UPIN
TN3909409Medicaid