Healthcare Provider Details

I. General information

NPI: 1093410342
Provider Name (Legal Business Name): RAQUEL RUDY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19229 MACK AVE STE 34
GROSSE POINTE WOODS MI
48236-2857
US

IV. Provider business mailing address

19229 MACK AVE STE 24
GROSSE POINTE WOODS MI
48236-2857
US

V. Phone/Fax

Practice location:
  • Phone: 313-647-3245
  • Fax: 313-647-3244
Mailing address:
  • Phone: 313-884-6057
  • Fax: 313-884-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number5151016269
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: