Basic Information
| Provider Information | |||||||||
| NPI: | 1295833630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUDNICK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | KLEIN, SUITE 202 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154568210 | ||||||||
| FaxNumber: | 2153291085 | ||||||||
| Practice Location | |||||||||
| Address1: | 5401 OLD YORK RD | ||||||||
| Address2: | KLEIN, SUITE 202 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154568210 | ||||||||
| FaxNumber: | 2153291085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD045109E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 05154105001 | 05 | PA | MEDICAID |