Provider Demographics
NPI:1386712081
Name:BENNETT L RUDORFER MD PA
Entity type:Organization
Organization Name:BENNETT L RUDORFER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUDORFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-732-3790
Mailing Address - Street 1:PO BOX 381974
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1974
Mailing Address - Country:US
Mailing Address - Phone:870-732-2398
Mailing Address - Fax:870-732-3647
Practice Address - Street 1:310 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4225
Practice Address - Country:US
Practice Address - Phone:870-732-2398
Practice Address - Fax:870-732-3647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C839Medicare PIN