Healthcare Provider Details

I. General information

NPI: 1700097698
Provider Name (Legal Business Name): TIFFANY F RUDLOE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 RESORT WAY
ELLSWORTH ME
04605-1717
US

IV. Provider business mailing address

50 UNION ST MAINE COAST PEDIATRICS
ELLSWORTH ME
04605-1534
US

V. Phone/Fax

Practice location:
  • Phone: 207-664-7744
  • Fax: 207-664-7724
Mailing address:
  • Phone: 207-664-7744
  • Fax: 207-664-7724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number227781
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD19683
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: