Healthcare Provider Details

I. General information

NPI: 1063041606
Provider Name (Legal Business Name): MARISSA RUGGIERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 WALNUT ST # 100
PHILADELPHIA PA
19107-5001
US

IV. Provider business mailing address

1025 WALNUT ST # 100
PHILADELPHIA PA
19107-5001
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6983
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number335024
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: