Provider Demographics
NPI:1801814686
Name:RUBIN, EDWARD M (PSY D)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:RUBIN
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2504
Mailing Address - Country:US
Mailing Address - Phone:414-454-6600
Mailing Address - Fax:414-454-6450
Practice Address - Street 1:1020 N 12TH ST
Practice Address - Street 2:OUTPT HEALTH CENTER 4TH FLOOR
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1308
Practice Address - Country:US
Practice Address - Phone:414-219-5000
Practice Address - Fax:414-219-5422
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1361057103T00000X
WI1361-057103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39080300Medicaid
R56479Medicare UPIN
WI001244285Medicare ID - Type Unspecified