1104831569 NPI number — RICK A RUBIN MD INC

Table of content: DR. JOHN L FLETCHER MD (NPI 1134566037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104831569 NPI number — RICK A RUBIN MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICK A RUBIN MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104831569
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 S LAKE AVE
Provider Second Line Business Mailing Address:
535
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91101-3005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-795-6596
Provider Business Mailing Address Fax Number:
626-795-8247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90403-5720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-264-7300
Provider Business Practice Location Address Fax Number:
310-828-8626
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUBIN
Authorized Official First Name:
RICK
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-612-6589

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  G36791 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G367910 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G367910 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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