Basic Information
| Provider Information | |||||||||
| NPI: | 1770582785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDICEL | ||||||||
| FirstName: | MAX | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | STE 130 PROVIDER ENROLLMENT | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7657473241 | ||||||||
| FaxNumber: | 7652816567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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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 | 01023414A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | 01023414A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 207Q00000X | 01023414A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | 01023414A | IN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 010028934 | 01 | IN | RAILROAD MEDICARE | OTHER | 100105790A | 05 | IN | MEDICAID | 000000082497 | 01 | IN | BLUE CROSS/BLUE SHIELD | OTHER | 100105790 | 05 | IN | MEDICAID |