Provider Demographics
NPI:1326029976
Name:WISE, RUDOLPH L (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:L
Last Name:WISE
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:PO BOX 2046
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-2046
Mailing Address - Country:US
Mailing Address - Phone:803-461-3000
Mailing Address - Fax:803-461-4910
Practice Address - Street 1:166 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-8239
Practice Address - Country:US
Practice Address - Phone:803-461-3000
Practice Address - Fax:803-461-4910
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8902207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC089022Medicaid
SC089022Medicaid