Healthcare Provider Details

I. General information

NPI: 1700868387
Provider Name (Legal Business Name): JAMES P RUDOLPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 JACKSON ST
OSHKOSH WI
54901-1513
US

IV. Provider business mailing address

2725 JACKSON ST
OSHKOSH WI
54901-1513
US

V. Phone/Fax

Practice location:
  • Phone: 920-223-7741
  • Fax:
Mailing address:
  • Phone: 920-223-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number753
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: