Healthcare Provider Details

I. General information

NPI: 1184706830
Provider Name (Legal Business Name): ELLEN TEMPLE BRUBECK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN TEMPLE BRUBECK M.D.

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 N BREAZEALE AVE
MOUNT OLIVE NC
28365-1121
US

IV. Provider business mailing address

1140 N BREAZEALE AVE
MOUNT OLIVE NC
28365-1121
US

V. Phone/Fax

Practice location:
  • Phone: 919-299-4800
  • Fax: 919-299-4802
Mailing address:
  • Phone: 919-299-4800
  • Fax: 919-299-4802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20911
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: