Provider Demographics
NPI:1952350332
Name:RUTLEDGE, TANYA M (MD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:M
Last Name:RUTLEDGE
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 1:763 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:678-985-2000
Mailing Address - Fax:678-985-1999
Practice Address - Street 1:763 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:678-985-2000
Practice Address - Fax:678-985-1999
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA045605207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00798718AMedicaid
GA309511OtherWELLCARE
GAG75792Medicare UPIN
GA309511OtherWELLCARE