Basic Information
| Provider Information | |||||||||
| NPI: | 1285668665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUBIN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ALVIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 AVALON COURT DR | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 5163528518 | ||||||||
| Practice Location | |||||||||
| Address1: | 4295 HEMPSTEAD TPKE | ||||||||
| Address2: | |||||||||
| City: | BETHPAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117145713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165796000 | ||||||||
| FaxNumber: | 5163528518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 120778 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00302103 | 05 | NY | MEDICAID | 110037591 | 01 | NY | MC RR | OTHER |