1588612964 NPI number — RANDI E RUBENZIK MD

Table of content: RANDI E RUBENZIK MD (NPI 1588612964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588612964 NPI number — RANDI E RUBENZIK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUBENZIK
Provider First Name:
RANDI
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1588612964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11130 N TATUM BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85028-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-494-1817
Provider Business Mailing Address Fax Number:
602-494-7103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11130 N TATUM BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85028-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-494-1817
Provider Business Practice Location Address Fax Number:
602-494-7103
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  26180 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1Z5232 . This is a "HEALTH NET" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 542557 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070013969 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 99S007000006 . This is a "MEDISUN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1588612964 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 1995262 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0869290 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7096132 . This is a "AETNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 188961600 . This is a "DEPT OF LABOR WORK COMP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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