Provider Demographics
NPI:1184626517
Name:RUBY, SAMUEL R (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:RUBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:207 N BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:610-521-0150
Mailing Address - Fax:610-521-0567
Practice Address - Street 1:1 BARTOL AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078
Practice Address - Country:US
Practice Address - Phone:610-521-0150
Practice Address - Fax:610-521-6493
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021993E207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA143152Medicare PIN
PA143152TNYMedicare ID - Type Unspecified