Basic Information
| Provider Information | |||||||||
| NPI: | 1801814686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUBIN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PSY D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532132504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546600 | ||||||||
| FaxNumber: | 4144546450 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N 12TH ST | ||||||||
| Address2: | OUTPT HEALTH CENTER 4TH FLOOR | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532331308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142195000 | ||||||||
| FaxNumber: | 4142195422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/09/2010 | ||||||||
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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 | 103T00000X | 1361057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist | 103TH0004X | 1361-057 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Health |
ID Information
| ID | Type | State | Issuer | Description | 39080300 | 05 | WI | MEDICAID |