Provider Demographics
NPI:1538251335
Name:GORAN T RUDIC MD SC
Entity type:Organization
Organization Name:GORAN T RUDIC MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:G
Authorized Official - Last Name:MANION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-281-0251
Mailing Address - Street 1:5663 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-4107
Mailing Address - Country:US
Mailing Address - Phone:414-281-0251
Mailing Address - Fax:414-281-0271
Practice Address - Street 1:5663 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-4107
Practice Address - Country:US
Practice Address - Phone:414-281-0251
Practice Address - Fax:414-281-0271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC5043OtherRAILROAD MEDICARE
WI21281600Medicaid