Healthcare Provider Details

I. General information

NPI: 1477652287
Provider Name (Legal Business Name): BRENT A RUDISEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 E MAIN ST
PLAINFIELD IN
46168-2706
US

IV. Provider business mailing address

11523 WILDLIFE CT
ZIONSVILLE IN
46077-2205
US

V. Phone/Fax

Practice location:
  • Phone: 317-204-6910
  • Fax:
Mailing address:
  • Phone: 317-413-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number02002497A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: