Healthcare Provider Details

I. General information

NPI: 1962629915
Provider Name (Legal Business Name): KIM RUDOLPH MCGLOTHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM LA'CHET RUDOLPH

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 WOODMERE BLVD
MONTGOMERY AL
36106-3065
US

IV. Provider business mailing address

4760 WOODMERE BLVD
MONTGOMERY AL
36106-3065
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-0814
  • Fax: 334-288-3417
Mailing address:
  • Phone: 334-288-0814
  • Fax: 334-288-3417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number31714
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: