Healthcare Provider Details

I. General information

NPI: 1487376604
Provider Name (Legal Business Name): BRIAN KIRK RUDOLPH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5187 US ROUTE 60 STE 13
HUNTINGTON WV
25705-2076
US

IV. Provider business mailing address

5664 FISHER BOWEN BRANCH RD
WAYNE WV
25570-5917
US

V. Phone/Fax

Practice location:
  • Phone: 304-733-5010
  • Fax:
Mailing address:
  • Phone: 304-544-9930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number110593
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: