Healthcare Provider Details

I. General information

NPI: 1275157513
Provider Name (Legal Business Name): BRIAN DUDLEY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 09/02/2024
Certification Date: 09/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

11937 CALLE TRUCKSESS
EL CAJON CA
92019-4007
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95155716
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.084591
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: