Provider Demographics
NPI:1194760660
Name:RUDOLPH, COUNCILL C (MD)
Entity type:Individual
Prefix:
First Name:COUNCILL
Middle Name:C
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:15 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:DECHERD
Mailing Address - State:TN
Mailing Address - Zip Code:37324-3887
Mailing Address - Country:US
Mailing Address - Phone:931-962-2273
Mailing Address - Fax:931-962-2202
Practice Address - Street 1:822 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2324
Practice Address - Country:US
Practice Address - Phone:931-723-7121
Practice Address - Fax:931-723-7133
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000025899208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3091133Medicaid
TN3091133Medicaid
TN3091133Medicare PIN