Provider Demographics
NPI:1871079855
Name:TUCCILLO, LAUREN RUTH (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:RUTH
Last Name:TUCCILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:853 N CHURCH ST STE 510
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3077
Mailing Address - Country:US
Mailing Address - Phone:864-560-6193
Mailing Address - Fax:
Practice Address - Street 1:853 N CHURCH ST STE 510
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3077
Practice Address - Country:US
Practice Address - Phone:864-560-6193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL61240207Q00000X
SC61240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCI8815019OtherMEDICARE PIN
SC612402Medicaid