Provider Demographics
NPI:1922120427
Name:RUTLEDGE, THERESA S (DO)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:S
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S PRICE ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1442
Mailing Address - Country:US
Mailing Address - Phone:304-329-1400
Mailing Address - Fax:304-329-1175
Practice Address - Street 1:300 S PRICE ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1442
Practice Address - Country:US
Practice Address - Phone:304-329-1400
Practice Address - Fax:304-329-1175
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2281208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006728Medicaid
WV001990080OtherBCBS
WV7376341Medicare PIN