Provider Demographics
NPI:1639263676
Name:RUDDERMAN, RANDAL (MD)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:RUDDERMAN
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 1:3400-C OLD MILTON PKWY,
Mailing Address - Street 2:STE 450
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-3707
Mailing Address - Country:US
Mailing Address - Phone:678-566-7200
Mailing Address - Fax:678-566-7210
Practice Address - Street 1:3400-C OLD MILTON PKWY,
Practice Address - Street 2:STE 450
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-3707
Practice Address - Country:US
Practice Address - Phone:678-566-7200
Practice Address - Fax:678-566-7210
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024863174400000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D30667Medicare UPIN
24BCBCLMedicare ID - Type Unspecified