Provider Demographics
NPI:1942216205
Name:RUTLEDGE, MARK (PT PHYSICAL THERAPIS)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:PT PHYSICAL THERAPIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 LONE TREE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-884-7880
Mailing Address - Fax:843-884-6635
Practice Address - Street 1:607 JOHNNIE DODDS BLVD STE A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3084
Practice Address - Country:US
Practice Address - Phone:843-884-7880
Practice Address - Fax:843-884-6635
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1753Medicaid
SCTH0260Medicaid
SCTH0260Medicaid