Basic Information
| Provider Information | |||||||||
| NPI: | 1942216205 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUTLEDGE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT PHYSICAL THERAPIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 586 LONE TREE DR | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438847880 | ||||||||
| FaxNumber: | 8438846635 | ||||||||
| Practice Location | |||||||||
| Address1: | 607 JOHNNIE DODDS BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438847880 | ||||||||
| FaxNumber: | 8438846635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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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 | 225100000X | 1588 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | GP1753 | 05 | SC | MEDICAID | TH0260 | 05 | SC | MEDICAID |