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General NPI Number Information
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NPI Number | 1194760660
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Entity Type | Individual
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Provider Name | COUNCILL C RUDOLPH MD
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Gender | Male
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Dates
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Enumeration Date | 06/18/2006
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Last Update Date | 04/14/2016
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Provider Practice Location Address
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Address Line | 822 MCARTHUR ST
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City | MANCHESTER
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State | TN
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Zip | 37355-2324
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Country | US
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Telephone | 931-723-7121
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Fax | 931-723-7133
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Provider Business Mailing Address
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Address Line | 15 VETERANS DR
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City | DECHERD
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State | TN
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Zip | 37324-3887
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Country | US
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Telephone | 931-962-2273
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Fax | 931-962-2202
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD0000025899
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License Number State | TN
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