Provider Demographics
NPI:1073509683
Name:MEDRANO, RUBEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:RUBEN
Middle Name:A
Last Name:MEDRANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1007
Mailing Address - Country:US
Mailing Address - Phone:309-734-1414
Mailing Address - Fax:309-734-0323
Practice Address - Street 1:1000 W HARLEM AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1007
Practice Address - Country:US
Practice Address - Phone:309-734-1414
Practice Address - Fax:309-734-0323
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036095457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371352599001Medicaid
IL371352599001Medicaid
ILL79321Medicare Oscar/Certification
ILL79322Medicare ID - Type UnspecifiedCLINIC