Provider Demographics
NPI:1508806175
Name:RUBERG, RAYMOND L (DO)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:L
Last Name:RUBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:36 HANOVER STREET
Mailing Address - City:CODORUS
Mailing Address - State:PA
Mailing Address - Zip Code:17311-0128
Mailing Address - Country:US
Mailing Address - Phone:717-229-2972
Mailing Address - Fax:717-229-0542
Practice Address - Street 1:36 HANOVER STREET
Practice Address - Street 2:
Practice Address - City:CODORUS
Practice Address - State:PA
Practice Address - Zip Code:17311-0128
Practice Address - Country:US
Practice Address - Phone:717-229-2972
Practice Address - Fax:717-229-0542
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004031L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005714300001Medicaid
PA0005714300001Medicaid
PAD77321Medicare UPIN