Basic Information
| Provider Information | |||||||||
| NPI: | 1457378309 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRUESDALE | ||||||||
| FirstName: | DORENDA | ||||||||
| MiddleName: | GREGG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 GOLD HILL RD | ||||||||
| Address2: | STE 107 | ||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297158907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033295131 | ||||||||
| FaxNumber: | 8033666600 | ||||||||
| Practice Location | |||||||||
| Address1: | 2633 CELANESE RD | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033295131 | ||||||||
| FaxNumber: | 8033666600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22650 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2006-00615 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080195108 | 01 | RAILROAD MEDICARE | OTHER | 066NX | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER | 226507 | 05 | SC | MEDICAID |