Provider Demographics
NPI:1649252651
Name:RUFFALO, PHILLIP J (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:RUFFALO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1213 15TH AVE W
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3800
Mailing Address - Country:US
Mailing Address - Phone:701-577-0319
Mailing Address - Fax:701-572-7438
Practice Address - Street 1:1213 15TH AVE W
Practice Address - Street 2:SUITE 250
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3800
Practice Address - Country:US
Practice Address - Phone:701-577-0319
Practice Address - Fax:701-572-7438
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM5897208600000X
MT3813208600000X
NDND3055208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0031720OtherMT MEDICAID
IDM5897OtherIDAHO LICENSE #
ND013760Medicaid
ND594OtherND BLUE CROSS BLUE SHIELD
MT3813OtherMT LICENSE #
NDD26254Medicare UPIN
ND594OtherND BLUE CROSS BLUE SHIELD