Provider Demographics
NPI:1699725952
Name:RUDISILL, LAWRENCE EDWIN JR (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EDWIN
Last Name:RUDISILL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8617
Mailing Address - Fax:
Practice Address - Street 1:1011 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4240
Practice Address - Country:US
Practice Address - Phone:864-242-4263
Practice Address - Fax:864-242-2250
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10481207XS0106X, 2086S0105X
WAMD612803392086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104817Medicaid
SC104817Medicaid
SCSC27487951Medicare PIN