Basic Information
Provider Information | |||||||||
NPI: | 1447297833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUBERY | ||||||||
FirstName: | BRYON | ||||||||
MiddleName: | EVAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 751803 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282751803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362772000 | ||||||||
FaxNumber: | 3362772050 | ||||||||
Practice Location | |||||||||
Address1: | 186 KIMEL PARK DR | ||||||||
Address2: |   | ||||||||
City: | WINSTON SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271036946 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362772000 | ||||||||
FaxNumber: | 3362772050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 10/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/06/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200100276 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | 200100276 | NC | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 200100276 | NC | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
ID | Type | State | Issuer | Description | 1286C | 01 | NC | BCBS | OTHER | 190065 | 01 | NC | MEDCOST | OTHER | 5905499 | 05 | NC |   | MEDICAID | 1447297833 | 05 | VA |   | MEDICAID | 7659265 | 01 | NC | AETNA | OTHER | 3810007248 | 05 | WV |   | MEDICAID | Q0027N | 05 | SC |   | MEDICAID | 41917 | 01 | NC | PARTNERS | OTHER |