Healthcare Provider Details

I. General information

NPI: 1912000944
Provider Name (Legal Business Name): JONATHAN M RUDERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N CLAIR #320
CHICAGE IL
60611
US

IV. Provider business mailing address

676 N CLAIR #320
CHICAGE IL
60611
US

V. Phone/Fax

Practice location:
  • Phone: 312-475-1000
  • Fax: 312-475-1006
Mailing address:
  • Phone: 312-475-1000
  • Fax: 312-475-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: