Healthcare Provider Details

I. General information

NPI: 1508821463
Provider Name (Legal Business Name): RUDY G THELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 UNIVERSITY AVE W
SAINT PAUL MN
55104-4001
US

IV. Provider business mailing address

1390 UNIVERSITY AVE W
SAINT PAUL MN
55104-4001
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-4800
  • Fax: 651-232-4899
Mailing address:
  • Phone: 651-232-4800
  • Fax: 651-232-4899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22039
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: