Healthcare Provider Details

I. General information

NPI: 1811216948
Provider Name (Legal Business Name): BRYAN RUDOLPH MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3411 WAYNE AVE 7TH FLOOR
BRONX NY
10467-2403
US

IV. Provider business mailing address

80 HOMESTEAD RD
TENAFLY NJ
07670-1109
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2332
  • Fax:
Mailing address:
  • Phone: 202-465-5307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number257025-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number257025
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: