Basic Information
| Provider Information | |||||||||
| NPI: | 1033184767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RHEUDASIL | ||||||||
| FirstName: | J. | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709957622 | ||||||||
| FaxNumber: | 7709957854 | ||||||||
| Practice Location | |||||||||
| Address1: | 5673 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 675 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788435400 | ||||||||
| FaxNumber: | 6788435449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 026926 | GA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2086S0129X | 026926 | GA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000635302 | 05 | GA | MEDICAID | 000635302Q | 05 | GA | MEDICAID | 000635302S | 05 | GA | MEDICAID | 000635302K | 05 | GA | MEDICAID | 000635302L | 05 | GA | MEDICAID | 000635302M | 05 | GA | MEDICAID | 000635302O | 05 | GA | MEDICAID | 000635302P | 05 | GA | MEDICAID | 000635302J | 05 | GA | MEDICAID | 000635302N | 05 | GA | MEDICAID | 000635302R | 05 | GA | MEDICAID |