Healthcare Provider Details

I. General information

NPI: 1275021420
Provider Name (Legal Business Name): BLAKE RUDESEAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 RIVERVIEW ST
FRANKLIN NC
28734-2658
US

IV. Provider business mailing address

62 TANGLEWOOD LN
FRANKLIN NC
28734-4677
US

V. Phone/Fax

Practice location:
  • Phone: 828-349-6800
  • Fax:
Mailing address:
  • Phone: 706-949-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number303321
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: