Provider Demographics
NPI:1790736486
Name:CRUDEN, THOMAS B (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:B
Last Name:CRUDEN
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 1:1049B ANNA KNAPP BLVD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3133
Mailing Address - Country:US
Mailing Address - Phone:843-849-8800
Mailing Address - Fax:843-849-8889
Practice Address - Street 1:1049B ANNA KNAPP BLVD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3133
Practice Address - Country:US
Practice Address - Phone:843-849-8800
Practice Address - Fax:843-849-8889
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7436207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC074369Medicaid
SC074369Medicaid