Provider Demographics
NPI:1538276084
Name:TRUDELL, DIANNE KAY (MD)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:KAY
Last Name:TRUDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:G-5085 WEST BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2922
Mailing Address - Country:US
Mailing Address - Phone:810-230-2400
Mailing Address - Fax:810-230-1616
Practice Address - Street 1:G-5085 WEST BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2922
Practice Address - Country:US
Practice Address - Phone:810-230-2400
Practice Address - Fax:810-230-1616
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDT048800207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP60370OtherBLUE CARE NETWORK
MI1102511962OtherBLUE CROSS BLUE SHIELD
MI1996631Medicaid
MIC1542OtherM-CARE
MI1826025002OtherHEALTH PLUS
MI4092874OtherAETNA
0P54720Medicare PIN
MIP60370OtherBLUE CARE NETWORK