Basic Information
Provider Information | |||||||||
NPI: | 1841287109 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUDDER | ||||||||
FirstName: | MICHIEL | ||||||||
MiddleName: | BRENT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11567 | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383080126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316610086 | ||||||||
FaxNumber: | 7316619702 | ||||||||
Practice Location | |||||||||
Address1: | 622 WEST MARKET STREET | ||||||||
Address2: |   | ||||||||
City: | BOLIVAR | ||||||||
State: | TN | ||||||||
PostalCode: | 38008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7316584500 | ||||||||
FaxNumber: | 7316584545 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2005 | ||||||||
LastUpdateDate: | 10/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | RN131561 | TN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 3909409 | 05 | TN |   | MEDICAID | MR0784276 | 01 |   | DEA | OTHER |