Provider Demographics
NPI:1083610513
Name:MEDINA, RUDY TOM (MD)
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:TOM
Last Name:MEDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-5197
Mailing Address - Country:US
Mailing Address - Phone:828-433-4484
Mailing Address - Fax:828-433-4487
Practice Address - Street 1:100 MEDICAL HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5197
Practice Address - Country:US
Practice Address - Phone:828-433-4484
Practice Address - Fax:828-433-4487
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700106208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC73943OtherMEDCOST
NC891019HMedicaid
NC1019HOtherBCBS OF NC
NC4455597OtherAETNA
NC12 41243OtherUNITED HEALTHCARE
NC12 41243OtherUNITED HEALTHCARE