Basic Information
| Provider Information | |||||||||
| NPI: | 1497965990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDOMIOTOV | ||||||||
| FirstName: | OLGA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12101 WOODCREST EXECUTIVE DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631415047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Practice Location | |||||||||
| Address1: | 11133 DUNN RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631366119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 2008014379 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 2008014379 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1497965990 | 05 | MO | MEDICAID | 1497965990 | 05 | IL | MEDICAID |