Provider Demographics
NPI:1871597450
Name:RUFUS JR, EDWARD A (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:RUFUS JR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E MILLER RD
Mailing Address - Street 2:
Mailing Address - City:EDELSTEIN
Mailing Address - State:IL
Mailing Address - Zip Code:61526-9740
Mailing Address - Country:US
Mailing Address - Phone:309-274-5200
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-691-7890
Practice Address - Fax:309-691-7898
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073126Medicaid
IL7200599OtherBLUE CROSS BLUE SHIELD
ILC42883Medicare UPIN
IL036073126Medicaid