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General NPI Number Information
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NPI Number | 1003839168
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Entity Type | Individual
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Provider Name | RUDOLPH OBO ADDY MD
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Gender | Male
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Dates
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Enumeration Date | 07/26/2006
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Last Update Date | 09/24/2020
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Provider Practice Location Address
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Address Line | 2093 HEALTH DR SW
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City | WYOMING
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State | MI
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Zip | 49519-9691
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Country | US
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Telephone | 616-252-5760
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Fax |
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Provider Business Mailing Address
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Address Line | 5900 BYRON CENTER AVE SW
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City | WYOMING
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State | MI
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Zip | 49519-9606
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 4301042270
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 2084S0012X
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Taxonomy Name | Sleep Medicine (Psychiatry & Neurology) Physician
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License Number | 4301042270
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License Number State | MI
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