Provider Demographics
NPI:1528180684
Name:RUPERT, EDWARD GAYNOR (MD,PA)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GAYNOR
Last Name:RUPERT
Suffix:
Gender:M
Credentials:MD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 KNOLLWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-7656
Mailing Address - Country:US
Mailing Address - Phone:301-372-1689
Mailing Address - Fax:
Practice Address - Street 1:8000 KNOLLWOOD ST
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-7656
Practice Address - Country:US
Practice Address - Phone:301-372-1689
Practice Address - Fax:301-372-1689
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0021364207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7114OtherBCBS OF MD
DC3521OtherBCBSNCA
DC3521OtherBCBSNCA
DC078848Medicare PIN