Provider Demographics
NPI:1053389239
Name:RUDISEL, KEVIN M (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:RUDISEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5420
Mailing Address - Fax:704-384-5424
Practice Address - Street 1:1500 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-4656
Practice Address - Country:US
Practice Address - Phone:704-384-5420
Practice Address - Fax:704-384-5424
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC34148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN34148Medicaid
NC8973841Medicaid
SCN34148Medicaid
NC8973841Medicaid