Basic Information
| Provider Information | |||||||||
| NPI: | 1205909967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVONICH | ||||||||
| FirstName: | RUDOLPH | ||||||||
| MiddleName: | FRANCIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 W FAIR AVE | ||||||||
| Address2: | SUITE 334 | ||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062253870 | ||||||||
| FaxNumber: | 9062254861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | 21241-875 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | 4301076776 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 0605210971 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 5184312 | 05 | MI | MEDICAID | P00412659 | 01 | RAILROAD MEDICARE | OTHER | 34966000 | 05 | WI | MEDICAID |