Basic Information
| Provider Information | |||||||||
| NPI: | 1073700647 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUDOLPH J. VELA M.D. INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 W. U.S. RTE 224 | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448838305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194480220 | ||||||||
| FaxNumber: | 4194480461 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 W. U.S. ROUTE 224 | ||||||||
| Address2: | |||||||||
| City: | TIFFIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448838305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194480220 | ||||||||
| FaxNumber: | 4194480461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | VELA | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4194480220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35053275 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0659498 | 05 | OH | MEDICAID | VE059662 | 01 | MEDICARE | OTHER |