Provider Demographics
NPI:1578694147
Name:RUDD, KIMBERLY B (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:RUDD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 FAISON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-3210
Mailing Address - Country:US
Mailing Address - Phone:803-935-5046
Mailing Address - Fax:803-935-5053
Practice Address - Street 1:220 FAISON DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3210
Practice Address - Country:US
Practice Address - Phone:803-935-5046
Practice Address - Fax:803-935-5053
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC260722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC260728Medicaid
SCAA35823353Medicare UPIN