Provider Demographics
NPI:1841250339
Name:TRUDEAU, EDWARD A (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:TRUDEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:319 E MADISON ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1035
Mailing Address - Country:US
Mailing Address - Phone:217-788-3377
Mailing Address - Fax:217-788-5505
Practice Address - Street 1:319 E MADISON ST STE 2A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1035
Practice Address - Country:US
Practice Address - Phone:217-788-3377
Practice Address - Fax:217-788-5505
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062396204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036062396Medicaid
IL678060Medicare ID - Type Unspecified