Provider Demographics
NPI:1972703809
Name:WALDEN, H. RUFFIN III (PT)
Entity type:Individual
Prefix:MR
First Name:H.
Middle Name:RUFFIN
Last Name:WALDEN
Suffix:III
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9469
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62791-9469
Mailing Address - Country:US
Mailing Address - Phone:217-547-9100
Mailing Address - Fax:217-547-9247
Practice Address - Street 1:1301 S KOKE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9252
Practice Address - Country:US
Practice Address - Phone:217-547-9100
Practice Address - Fax:217-547-9247
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-0014742251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00769841OtherRAILROAD MEDICARE
IL916500OtherMEDICARE ID #
ILP00769841OtherRAILROAD MEDICARE