Healthcare Provider Details

I. General information

NPI: 1780144196
Provider Name (Legal Business Name): EMMA RUDEBUSCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 N MAIN ST
BLACKSTONE VA
23824-1425
US

IV. Provider business mailing address

213 N MAIN ST
BLACKSTONE VA
23824-1425
US

V. Phone/Fax

Practice location:
  • Phone: 434-292-7261
  • Fax:
Mailing address:
  • Phone: 434-292-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101282768
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number323237
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: