Basic Information
| Provider Information | |||||||||
| NPI: | 1952388712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDOLF | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 ALICE PECK DAY DR UNIT C | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034486344 | ||||||||
| FaxNumber: | 6034483405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 05/08/2017 | ||||||||
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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 | 207X00000X | 7449 | NH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | 7449 | NH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 0420007597 | VT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 30207509 | 05 | NH | MEDICAID | VN224302 | 01 | NH | MEDICARE B PTAN | OTHER | NH0016 | 01 | NH | MEDICARE PTAN | OTHER | 0009184 | 05 | VT | MEDICAID |