Provider Demographics
NPI:1326010109
Name:RUDICH, KERRY D (PT)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:D
Last Name:RUDICH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 EAST AVE
Mailing Address - Street 2:SUITE 2M
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5721
Mailing Address - Country:US
Mailing Address - Phone:203-866-5454
Mailing Address - Fax:203-354-6182
Practice Address - Street 1:2 CORPORATE DR
Practice Address - Street 2:SUITE 233
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6238
Practice Address - Country:US
Practice Address - Phone:203-924-5370
Practice Address - Fax:203-924-5372
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000300Medicare ID - Type Unspecified