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General NPI Number Information
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NPI Number | 1841287109
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Entity Type | Individual
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Provider Name | MICHIEL BRENT RUDDER FNP MSW
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Gender | Male
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Dates
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Enumeration Date | 10/03/2005
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 622 WEST MARKET STREET
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City | BOLIVAR
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State | TN
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Zip | 38008
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Country | US
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Telephone | 731-658-4500
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Fax | 731-658-4545
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Provider Business Mailing Address
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Address Line | PO BOX 11567
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City | JACKSON
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State | TN
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Zip | 38308-0126
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Country | US
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Telephone | 731-661-0086
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Fax | 731-661-9702
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | RN131561
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License Number State | TN
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