Provider Demographics
NPI:1093762999
Name:DERUBERTIS, ALBERT J (DO)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:J
Last Name:DERUBERTIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W HOMER ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4358
Mailing Address - Country:US
Mailing Address - Phone:219-879-8511
Mailing Address - Fax:
Practice Address - Street 1:301 W HOMER ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4358
Practice Address - Country:US
Practice Address - Phone:219-879-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081549208100000X
IN020-04394A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081549Medicaid
IL4673170001OtherDMERC GROUP
IL4673170001OtherDMERC GROUP
ILP00005971/CK6883Medicare PIN
ILF400182562Medicare PIN
ILP00005964/CK6882Medicare PIN
F15581Medicare UPIN
IL036081549Medicaid