Healthcare Provider Details

I. General information

NPI: 1043498512
Provider Name (Legal Business Name): KENNETH H. RUDOLPH, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 JEFFERSON AVE
SCRANTON PA
18510-1038
US

IV. Provider business mailing address

802 JEFFERSON AVE
SCRANTON PA
18510-1038
US

V. Phone/Fax

Practice location:
  • Phone: 570-343-3999
  • Fax: 570-343-2749
Mailing address:
  • Phone: 570-343-3999
  • Fax: 570-343-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KENNETH H RUDOLPH
Title or Position: OWNER
Credential: MD
Phone: 570-343-3999