Provider Demographics
NPI:1053403055
Name:RUDAWSKI, STEPHEN M (DO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:RUDAWSKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-7650
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3170
Practice Address - Fax:217-383-7650
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00362629OtherRAILROAD
IL0533210001OtherDMERC
ILP00362629OtherRAILROAD
IL6447860007Medicare NSC
I63762Medicare UPIN
ILI63762Medicare UPIN
ILIL3270280Medicare PIN