Healthcare Provider Details

I. General information

NPI: 1780492777
Provider Name (Legal Business Name): MR. COLLIN WOLFE RUDDELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8044 MONTGOMERY RD STE 120
CINCINNATI OH
45236-2919
US

IV. Provider business mailing address

637 ASPEN LN
BOWLING GREEN OH
43402-1454
US

V. Phone/Fax

Practice location:
  • Phone: 513-607-5128
  • Fax:
Mailing address:
  • Phone: 419-503-7102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.005608
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: