Basic Information
| Provider Information | |||||||||
| NPI: | 1699262683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUBAKHA | ||||||||
| FirstName: | MIKHAIL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| OtherLastName: | ROUBAKHA | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4525 LINDELL BLVD APT 503 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631082013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674218059 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 836 W WELLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606575147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732965424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | IL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.