Healthcare Provider Details

I. General information

NPI: 1104588839
Provider Name (Legal Business Name): MELODY C BOLTON RUDI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2021
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 RIDENOUR BLVD NW STE 300
KENNESAW GA
30152-4402
US

IV. Provider business mailing address

476 WILMER ST NE UNIT 1113
ATLANTA GA
30308-2934
US

V. Phone/Fax

Practice location:
  • Phone: 985-722-7993
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number10618
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number10618
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: