Basic Information
| Provider Information | |||||||||
| NPI: | 1922084342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDLOFF | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 109 | ||||||||
| Address2: | |||||||||
| City: | NELIGH | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687560109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028875440 | ||||||||
| FaxNumber: | 4028874564 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 W 11TH ST | ||||||||
| Address2: | |||||||||
| City: | NELIGH | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687561065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028875440 | ||||||||
| FaxNumber: | 4028874564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19913 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NE19913 | 05 | NE | MEDICAID |