Provider Demographics
NPI:1295836617
Name:RUDOLPH, RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:RUDOLPH
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 1:4700 WATERS AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-2700
Mailing Address - Fax:912-350-2715
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-2700
Practice Address - Fax:912-350-2715
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30205208600000X
SC21641208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000453043LMedicaid
GA10065386OtherAMERIGROUP
GA000453043EMedicaid
SCP00955061OtherRAILROAD MEDICARE
GA000453043IMedicaid
GA000453043MMedicaid
GA020047969OtherRAILROAD MEDICARE
SC020050906OtherRAILROAD MEDICARE
GA349825OtherWELLCARE
GA000453043BMedicaid
GA000453043DMedicaid
GA000453043GMedicaid
GAP00955071OtherRAILROAD MEDICARE
GA000453043JMedicaid
SCG30205Medicaid
GA020047969OtherRAILROAD MEDICARE
GA000453043GMedicaid
GA000453043MMedicaid
GA02BBCNTMedicare PIN
GA000453043JMedicaid
SCSC00757416Medicare PIN