Healthcare Provider Details

I. General information

NPI: 1619073491
Provider Name (Legal Business Name): EDMUNDO RAUL RUBIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CRYSTAL SPRING AVE SW SUITE 205
ROANOKE VA
24014-2462
US

IV. Provider business mailing address

2001 CRYSTAL SPRING AVE SW SUITE 205
ROANOKE VA
24014-2462
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-8505
  • Fax: 540-344-3313
Mailing address:
  • Phone: 540-985-8505
  • Fax: 540-344-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number17151
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number17151
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101-243666
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101-243666
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: