Basic Information
| Provider Information | |||||||||
| NPI: | 1164022711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDDEROW | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 SOFIA CT | ||||||||
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| City: | BLACKWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080125379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096178915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 113 ROUTE 73 | ||||||||
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| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080439573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568093500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2020 | ||||||||
| LastUpdateDate: | 10/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 46TA09202600 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.