MEDICARE: MICHAEL D RUDISILL LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	36000021

General Provider Information

NPI Number	:	1447689765
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL D RUDISILL LAT, ATC

Provider Business Mailing Address
First Line	:	8429 KANSA CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46217-5015
Country	:	US
Telephone Number	:	317-694-4526
Fax Number	:

Provider Business Practice Location Address
First Line	:	8429 KANSA CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46217-5015
Country	:	US
Telephone Number	:	317-694-4526
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/07/2013

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