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General NPI Number Information
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NPI Number | 1336400043
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Entity Type | Organization
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Legal Business Name | RANDALL L. RUDEEN MD PA
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Dates
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Enumeration Date | 05/30/2012
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Last Update Date | 05/30/2012
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Provider Practice Location Address
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Address Line | 1603 12TH AVE RD SUITE B
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City | NAMPA
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State | ID
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Zip | 83686-7712
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Country | US
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Telephone | 208-467-2400
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Fax | 208-467-6416
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Provider Business Mailing Address
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Address Line | 1603 12TH AVE RD SUITE B
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City | NAMPA
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State | ID
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Zip | 83686-7712
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Country | US
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Telephone | 208-467-2400
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Fax | 208-467-6416
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. RANDALL L RUDEEN
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Credential | M.D.
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Telephone | 208-467-2400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | M5040
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License Number State | ID
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