Basic Information
| Provider Information | |||||||||
| NPI: | 1619073491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUBIO | ||||||||
| FirstName: | EDMUNDO | ||||||||
| MiddleName: | RAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 CRYSTAL SPRING AVE SW | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240142462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409858505 | ||||||||
| FaxNumber: | 5403443313 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 CRYSTAL SPRING AVE SW | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240142462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409858505 | ||||||||
| FaxNumber: | 5403443313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 17151 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 17151 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 0101-243666 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 0101-243666 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00124283 | 05 | MS | MEDICAID |