Provider Demographics
NPI:1457378309
Name:TRUESDALE, DORENDA GREGG (MD)
Entity Type:Individual
Prefix:
First Name:DORENDA
Middle Name:GREGG
Last Name:TRUESDALE
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 1:704 GOLD HILL RD
Mailing Address - Street 2:STE 107
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-8907
Mailing Address - Country:US
Mailing Address - Phone:803-329-5131
Mailing Address - Fax:803-366-6600
Practice Address - Street 1:2633 CELANESE RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1205
Practice Address - Country:US
Practice Address - Phone:803-329-5131
Practice Address - Fax:803-366-6600
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22650207Q00000X
NC2006-00615207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080195108OtherRAILROAD MEDICARE
NC066NXOtherBLUE CROSS BLUE SHIELD NC
SC226507Medicaid
NC066NXOtherBLUE CROSS BLUE SHIELD NC
SC226507Medicaid
SCH785544592Medicare PIN