1083610513 NPI number — RUDY TOM MEDINA MD

Table of content: RUDY TOM MEDINA MD (NPI 1083610513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083610513 NPI number — RUDY TOM MEDINA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
RUDY
Provider Middle Name:
TOM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083610513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MEDICAL HEIGHTS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28655-5197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-433-4484
Provider Business Mailing Address Fax Number:
828-433-4487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MEDICAL HEIGHTS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28655-5197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-433-4484
Provider Business Practice Location Address Fax Number:
828-433-4487
Provider Enumeration Date:
06/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  9700106 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 73943 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891019H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1019H . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4455597 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 12 41243 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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