Provider Demographics
NPI:1528336880
Name:LORI WILLIAMS-RUDALAVAGE MD LLC
Entity type:Organization
Organization Name:LORI WILLIAMS-RUDALAVAGE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-230-0036
Mailing Address - Street 1:157 SCRANTON CARBONDALE HWY
Mailing Address - Street 2:PINELINE PLAZA
Mailing Address - City:EYNON
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1027
Mailing Address - Country:US
Mailing Address - Phone:570-230-0036
Mailing Address - Fax:570-230-0042
Practice Address - Street 1:157 SCRANTON CARBONDALE HWY
Practice Address - Street 2:PINELINE PLAZA
Practice Address - City:EYNON
Practice Address - State:PA
Practice Address - Zip Code:18403-1027
Practice Address - Country:US
Practice Address - Phone:570-230-0036
Practice Address - Fax:570-230-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD057902L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2680260OtherPA BLUE SHIELD
PA616435200OtherUS DEPT OF LABOR- FECA/BLACK LUNG
PA232204Medicare PIN