Basic Information
| Provider Information | |||||||||
| NPI: | 1770520538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDDY | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 917110 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328917110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009012102 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 AVENUE 'B', NW | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632914000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 08/18/2010 | ||||||||
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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 | 207L00000X | ME67160 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 26262 | 01 | FL | BLUE CROSS BLUE SHIELD FL | OTHER | 376422200 | 05 | FL | MEDICAID | 50056275 | 01 | FL | RAILROAD MEDICARE | OTHER | SSN | 01 | FL | TRICARE/CHAMPUS | OTHER |