Provider Demographics
NPI:1306854583
Name:BRYAN RUBACH M D SC
Entity type:Organization
Organization Name:BRYAN RUBACH M D SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SABON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-820-8653
Mailing Address - Street 1:1256 WATERFORD DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4510
Mailing Address - Country:US
Mailing Address - Phone:630-820-8653
Mailing Address - Fax:630-820-7238
Practice Address - Street 1:1256 WATERFORD DR
Practice Address - Street 2:SUITE 170
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4510
Practice Address - Country:US
Practice Address - Phone:630-820-8653
Practice Address - Fax:630-820-7238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL040008621OtherRAIL ROAD MEDICARE
IL4506907OtherBCBS
7642444OtherAETNA
IL205598Medicare PIN