Healthcare Provider Details

I. General information

NPI: 1609175421
Provider Name (Legal Business Name): RANDAL H. RUDDERMAN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400-C OLD MILTON PKWY, STE 450
ALPHARETTA GA
30005-3707
US

IV. Provider business mailing address

3400-C OLD MILTON PKWY, STE 450
ALPHARETTA GA
30005-3707
US

V. Phone/Fax

Practice location:
  • Phone: 678-566-7200
  • Fax: 678-566-7210
Mailing address:
  • Phone: 678-566-7200
  • Fax: 678-566-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number024863
License Number StateGA

VIII. Authorized Official

Name: RANDAL RUDDERMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 678-566-7200