Basic Information
| Provider Information | |||||||||
| NPI: | 1992179865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDIC | ||||||||
| FirstName: | MIRJANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RADIVOJEVIC | ||||||||
| OtherFirstName: | MIRJANA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 350 | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980380350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253580956 | ||||||||
| FaxNumber: | 8774816931 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 BELLEVUE WAY NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980045720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254555596 | ||||||||
| FaxNumber: | 4254513248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2015 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HA 60437694 | WA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2049826 | 05 | WA | MEDICAID |