Healthcare Provider Details

I. General information

NPI: 1508538000
Provider Name (Legal Business Name): AMY A RUDBERG LIC. ACUPUNCTURIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2021
Last Update Date: 10/02/2021
Certification Date: 10/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 N ASTOR ST APT 5SE
CHICAGO IL
60610-6712
US

IV. Provider business mailing address

1555 N ASTOR ST APT 5SE
CHICAGO IL
60610-6712
US

V. Phone/Fax

Practice location:
  • Phone: 312-944-6353
  • Fax:
Mailing address:
  • Phone: 312-944-6353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.001545
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.019923
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: