Provider Demographics
NPI:1861406738
Name:A. H. RUDBERG UROLOGY PC
Entity type:Organization
Organization Name:A. H. RUDBERG UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVIDAH
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUDBERG
Authorized Official - Suffix:X
Authorized Official - Credentials:MD
Authorized Official - Phone:718-934-7800
Mailing Address - Street 1:156 BEACH 143RD ST
Mailing Address - Street 2:
Mailing Address - City:NEPONSIT
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1105
Mailing Address - Country:US
Mailing Address - Phone:718-634-1404
Mailing Address - Fax:718-634-1404
Practice Address - Street 1:231 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6824
Practice Address - Country:US
Practice Address - Phone:718-934-7800
Practice Address - Fax:718-934-3732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190637-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWRA971Medicare PIN