Provider Demographics
NPI:1871578740
Name:RUDISILL, DOUGLAS
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:RUDISILL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5947
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1820
Practice Address - Country:US
Practice Address - Phone:509-765-5606
Practice Address - Fax:253-838-6418
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42852146D00000X
WAMD60041375207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9111RUOtherBSWA
WA0243670OtherLIWA
WA0243670OtherVCR
WA8531188Medicaid
WA0243670OtherVCR