Provider Demographics
NPI:1699754622
Name:RAUBA, GERALD ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ALAN
Last Name:RAUBA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 51ST ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6621
Mailing Address - Country:US
Mailing Address - Phone:309-797-9626
Mailing Address - Fax:
Practice Address - Street 1:2108 41ST ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-4579
Practice Address - Country:US
Practice Address - Phone:309-764-7535
Practice Address - Fax:309-764-8022
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038004000Medicaid