Provider Demographics
NPI:1881717049
Name:RUDEN, ANDREW J
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:RUDEN
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 1:29600 S WIXOM RD
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-3430
Mailing Address - Country:US
Mailing Address - Phone:248-926-8459
Mailing Address - Fax:248-926-1310
Practice Address - Street 1:29600 S WIXOM RD
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-3430
Practice Address - Country:US
Practice Address - Phone:248-926-8459
Practice Address - Fax:248-926-1310
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040917208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA76068Medicare UPIN