Provider Demographics
NPI:1609815059
Name:RABUN, ELLEN I (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:I
Last Name:RABUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 ALBEMARLE LN
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-8116
Mailing Address - Country:US
Mailing Address - Phone:540-951-9444
Mailing Address - Fax:540-951-3270
Practice Address - Street 1:6103 ALBEMARLE LANE
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-3351
Practice Address - Country:US
Practice Address - Phone:540-951-9444
Practice Address - Fax:540-951-3270
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055151207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA219203OtherANTHEM
VA219204OtherANTHEM
VA005628971Medicaid
VA005628971Medicaid
080008000Medicare PIN
VAP00476632Medicare PIN
VA00X601B01Medicare PIN