Provider Demographics
NPI:1083686661
Name:RUMBAOA, PHILIP L (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:L
Last Name:RUMBAOA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PHILIP
Other - Middle Name:
Other - Last Name:RUMBAOA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1330 GRACE LN
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-2146
Mailing Address - Country:US
Mailing Address - Phone:660-537-0285
Mailing Address - Fax:
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-635-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115065202K00000X, 207Q00000X
KS0426821202K00000X, 207Q00000X
MO2000163033207Q00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO25213101OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
KS25213121OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
MOW658522Medicare PIN
KS25213121OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
KSB068522Medicare PIN