Provider Demographics
NPI:1023129954
Name:RUGEN, REBECCA V
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:V
Last Name:RUGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 GRAHAM RD STE C-2320
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8030
Mailing Address - Country:US
Mailing Address - Phone:314-953-6801
Mailing Address - Fax:314-953-6819
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:STE 2320C
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-953-6801
Practice Address - Fax:314-953-6819
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207917212Medicaid
F78908Medicare UPIN
MO207917212Medicaid