Provider Demographics
NPI:1871587113
Name:RUDOLPH, PRIYA (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:706-369-4478
Mailing Address - Fax:706-353-6639
Practice Address - Street 1:125 KING AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6734
Practice Address - Country:US
Practice Address - Phone:706-369-4478
Practice Address - Fax:706-353-6639
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068852207RH0003X, 207RH0003X
IN01060195A207RX0202X
OH35084457207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129225CMedicaid
GAP01155926OtherRR MEDICARE
GA003129225BMedicaid
GA003129225CMedicaid
I05894Medicare UPIN
I05894Medicare UPIN
IN200479520Medicaid
IN176760OMedicare PIN
GA003129225BMedicaid
OH2484011Medicaid