MEDICARE: HOLLI K RUBY DO

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	207Q00000X	Family Medicine Physician	118003	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	080174612	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	148980	OTHER	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	389677	OTHER	HEALTHLINK

General Provider Information

NPI Number	:	1508801580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLI K RUBY DO

Provider Business Mailing Address
First Line	:	PO BOX 1359
Second Line	:
City	:	AVA
State	:	MO
Zip	:	65608-1359
Country	:	US
Telephone Number	:	417-683-4831
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 NW 10TH AVE.
Second Line	:
City	:	AVA
State	:	MO
Zip	:	65608-1359
Country	:	US
Telephone Number	:	417-683-4831
Fax Number	:	417-683-1602

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	10/26/2015

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Directions to “ HOLLI K RUBY DO” Practice Location

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