Basic Information
Provider Information | |||||||||
NPI: | 1467402867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUBLE | ||||||||
FirstName: | CRAIG | ||||||||
MiddleName: | RICHARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12639 OLD TESSON RD | ||||||||
Address2: | SUITE 115 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631282786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3148490311 | ||||||||
FaxNumber: | 3148494423 | ||||||||
Practice Location | |||||||||
Address1: | 1390 HIGHWAY 61 | ||||||||
Address2: | JHM MOC SUITE G1000 | ||||||||
City: | FESTUS | ||||||||
State: | MO | ||||||||
PostalCode: | 630284137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6369337400 | ||||||||
FaxNumber: | 6369337403 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/10/2006 | ||||||||
LastUpdateDate: | 07/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2002008842 | MO | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0901515 | 01 | MO | UNITED HEALTHCARE | OTHER | 185342 | 01 | MO | BLUE CROSS BLUE SHIELD | OTHER | 7075347 | 01 | MO | AETNA | OTHER | 482186 | 01 | MO | HEALTHLINK | OTHER | 189058 | 01 | MO | GROUP HEALTH PLAN | OTHER | 206023715 | 05 | MO |   | MEDICAID | P00065237 | 01 | MO | RAILROAD MEDICARE | OTHER |