MEDICARE: JAMES RUBY ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		PA

General Provider Information

NPI Number	:	1083113815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES RUBY ATC

Provider Business Mailing Address
First Line	:	923 WESCHLER AVE APT 3
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16502-1074
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 UNIVERSITY SQ
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16541-0001
Country	:	US
Telephone Number	:	814-871-7420
Fax Number	:	814-871-5606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2018
Last Update Date	:	11/30/2020

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