Healthcare Provider Details

I. General information

NPI: 1487072229
Provider Name (Legal Business Name): JASON ROSS RUDMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2014
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 380C
SAINT LOUIS MO
63131
US

IV. Provider business mailing address

3009 N BALLAS RD STE 380C
SAINT LOUIS MO
63131-2324
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-4790
  • Fax: 314-996-4792
Mailing address:
  • Phone: 314-996-4790
  • Fax: 314-996-4792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2019016866
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: