Provider Demographics
NPI:1184706830
Name:BRUBECK, ELLEN TEMPLE (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:TEMPLE
Last Name:BRUBECK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ELLEN
Other - Middle Name:TEMPLE
Other - Last Name:BRUBECK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1140 N BREAZEALE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:NC
Mailing Address - Zip Code:28365-1121
Mailing Address - Country:US
Mailing Address - Phone:919-299-4800
Mailing Address - Fax:919-299-4802
Practice Address - Street 1:1140 N BREAZEALE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1121
Practice Address - Country:US
Practice Address - Phone:919-299-4800
Practice Address - Fax:919-299-4802
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406028Medicaid
NC8919280Medicaid
NC19284OtherBCBS
NC205089CMedicare ID - Type UnspecifiedOFFICE WORK
NC205089DMedicare ID - Type UnspecifiedNURSING HOME WORK
NC8919280Medicaid