Healthcare Provider Details

I. General information

NPI: 1316580483
Provider Name (Legal Business Name): CARLY ELIZABETH RUGGIERIO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY ELIZABETH BLACK

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE STREET
PHILADELPHIA PA
19104-4206
US

IV. Provider business mailing address

3400 SPRUCE STREET
PHILADELPHIA PA
19104-4206
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2096
  • Fax: 215-349-5895
Mailing address:
  • Phone: 215-662-2096
  • Fax: 215-349-5895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061151
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: