Basic Information
| Provider Information | |||||||||
| NPI: | 1134128341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUFFA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LECOM PL | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165052571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148682507 | ||||||||
| FaxNumber: | 8148682522 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 PARADE ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165042809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144526383 | ||||||||
| FaxNumber: | 8144521427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | OS007632L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 207Q00000X | OS15523 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS007632L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0014128860013 | 05 | PA | MEDICAID |