Provider Demographics
NPI:1528209293
Name:JACKSON, RUBIE SUE (MD)
Entity Type:Individual
Prefix:
First Name:RUBIE
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RUBIE
Other - Middle Name:SUE
Other - Last Name:MAYBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915
Mailing Address - Country:US
Mailing Address - Phone:443-481-6573
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2000 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:443-481-5300
Practice Address - Fax:443-481-6705
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD77385208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD213518300Medicaid
356807Y5ZMedicare PIN