Healthcare Provider Details

I. General information

NPI: 1699780155
Provider Name (Legal Business Name): FREDERICK W. RUPP JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD. NE UNM HOSPITAL
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

933 BRADBURY DR. SE SUITE 2222
ALBUQUERQUE NM
87106
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-0011
  • Fax: 505-272-5821
Mailing address:
  • Phone: 505-272-3120
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number91-293
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: