Provider Demographics
NPI:1912926205
Name:RUBACH, BRYAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:RUBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 OGDEN AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7205
Mailing Address - Country:US
Mailing Address - Phone:630-978-6895
Mailing Address - Fax:630-375-2905
Practice Address - Street 1:2040 OGDEN AVE STE 301
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7205
Practice Address - Country:US
Practice Address - Phone:630-978-6895
Practice Address - Fax:630-375-2905
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL364032123207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4506907OtherBLUE CROSS BLUE SHIELD
ILF80995Medicaid
IL040008621OtherRAILROAD MEDICARE
IL040008621OtherRAILROAD MEDICARE