Provider Demographics
NPI:1437154325
Name:RUBLES, KATHI (MD)
Entity Type:Individual
Prefix:
First Name:KATHI
Middle Name:
Last Name:RUBLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19785 W 12 MILE RD
Mailing Address - Street 2:# 857
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29350 SOUTHFIELD RD
Practice Address - Street 2:STE 122
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2020
Practice Address - Country:US
Practice Address - Phone:313-343-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4169920Medicaid
MI0M91120Medicare ID - Type Unspecified
MI4169920Medicaid