Basic Information
| Provider Information | |||||||||
| NPI: | 1124122700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDORFER | ||||||||
| FirstName: | BENNETT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 381974 | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381831974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018210338 | ||||||||
| FaxNumber: | 9018210341 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 WEST TYLER | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707322398 | ||||||||
| FaxNumber: | 8707323647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N8396 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 124411001 | 05 | AR | MEDICAID |