Healthcare Provider Details

I. General information

NPI: 1457584138
Provider Name (Legal Business Name): PETER MITCHELL RUDERMAN M.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 LADUE RD
SAINT LOUIS MO
63124-2079
US

IV. Provider business mailing address

8820 LADUE ROAD
ST. LOUIS MO
63124
US

V. Phone/Fax

Practice location:
  • Phone: 314-754-3253
  • Fax:
Mailing address:
  • Phone: 314-754-3253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number000742
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: