Basic Information
| Provider Information | |||||||||
| NPI: | 1609029420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDD | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | WALKER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD, MPH, DABFM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 DEWEY FIELD RD | ||||||||
| Address2: | 2ND FLOOR- HB7256 | ||||||||
| City: | HANOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037551419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036504000 | ||||||||
| FaxNumber: | 6036462268 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 OLD ETNA RD | ||||||||
| Address2: | DHMC DEPARTMENT OF FAMILY MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036504000 | ||||||||
| FaxNumber: | 6036504190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2008 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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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 | 207P00000X | 15514 | NH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 042414 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 042414 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25MA07905200 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 15514 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 042.0012952 | VT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1020400 | 05 | VT | MEDICAID | 32001365 | 05 | NH | MEDICAID |