MEDICARE: JOHN R RUDISILL

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	103TC0700X	Clinical Psychologist	2565	OH

General Provider Information

NPI Number	:	1871594853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN R RUDISILL

Provider Business Mailing Address
First Line	:	1020 WOODMAN DR
Second Line	:	SUITE 225
City	:	DAYTON
State	:	OH
Zip	:	45432-1446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1020 WOODMAN DR
Second Line	:	SUITE 225
City	:	DAYTON
State	:	OH
Zip	:	45432-1446
Country	:	US
Telephone Number	:	937-254-9210
Fax Number	:

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/08/2007

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