Healthcare Provider Details

I. General information

NPI: 1023242195
Provider Name (Legal Business Name): JONATHAN W. RUTLEDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N BELAIR RD
EVANS GA
30809-3000
US

IV. Provider business mailing address

340 N BELAIR RD
EVANS GA
30809-3000
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-5676
  • Fax: 706-722-2824
Mailing address:
  • Phone: 706-868-5676
  • Fax: 706-722-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number071628
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: