Basic Information
| Provider Information | |||||||||
| NPI: | 1316367196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUBIN | ||||||||
| FirstName: | GREGORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240940 | ||||||||
| FaxNumber: | 2396240941 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240940 | ||||||||
| FaxNumber: | 2396240941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2014 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 04125 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207R00000X | OS14970 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207QS0010X | OS14970 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100187700 | 05 | FL | MEDICAID | T5A5K | 01 | FL | BCBS | OTHER | JL158 | 01 | FL | MEDICARE | OTHER |