Provider Demographics
NPI:1073626594
Name:RUBINO, IDA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:JEAN
Last Name:RUBINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:JEAN
Other - Last Name:RUBINO-RICCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44250 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1002
Practice Address - Country:US
Practice Address - Phone:248-964-0400
Practice Address - Fax:248-964-0402
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3403008Medicaid
MI3403008Medicaid
0N58330Medicare ID - Type Unspecified