Healthcare Provider Details

I. General information

NPI: 1700877289
Provider Name (Legal Business Name): KEITH DOYLE RUFFCORN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 LOGAN AVE EMERGENCY DEPARTMENT
WATERLOO IA
50703-1916
US

IV. Provider business mailing address

1229 S HILL DR
WATERLOO IA
50701-5046
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-3697
  • Fax: 319-235-3844
Mailing address:
  • Phone: 319-235-6431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number22469
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: