Healthcare Provider Details

I. General information

NPI: 1093430266
Provider Name (Legal Business Name): MADISON KATHLEEN RUZICKA HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADISON KATHLEEN CORNELISON

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 ROTTINGHAM CT STE C
EDWARDSVILLE IL
62025-3778
US

IV. Provider business mailing address

123 ROTTINGHAM CT STE C
EDWARDSVILLE IL
62025-3778
US

V. Phone/Fax

Practice location:
  • Phone: 618-655-1385
  • Fax: 618-655-1393
Mailing address:
  • Phone: 618-655-1385
  • Fax: 618-655-1393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3467
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: