Provider Demographics
NPI:1659331445
Name:MOORE, ILENE RUBOWITZ (MD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:RUBOWITZ
Last Name:MOORE
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 1:14001 RIDGEDALE DR
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1753
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14001 RIDGEDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55305-1781
Practice Address - Country:US
Practice Address - Phone:952-473-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45291208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN913119100Medicaid
MN913119100Medicaid