Healthcare Provider Details

I. General information

NPI: 1932335130
Provider Name (Legal Business Name): RAFAEL MIGUEL RUGGIERI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 FIELDS SOUTH DR
CHAMPAIGN IL
61822-3743
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3909
US

V. Phone/Fax

Practice location:
  • Phone: 217-366-1228
  • Fax: 217-366-6106
Mailing address:
  • Phone: 217-366-1228
  • Fax: 217-366-6106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036141048
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: