Basic Information
Provider Information | |||||||||
NPI: | 1437137999 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUEBEL | ||||||||
FirstName: | G. | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 728 134TH ST SW | ||||||||
Address2: | SUITE 120 | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982045322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252976200 | ||||||||
FaxNumber: | 4252976250 | ||||||||
Practice Location | |||||||||
Address1: | 1321 COLBY AVENUE | ||||||||
Address2: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 98206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252612000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/05/2006 | ||||||||
LastUpdateDate: | 11/01/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | MD00012413 | WA | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | MD00012413 | WA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 8125247 | 05 | WA |   | MEDICAID | 202652 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 162883 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 202651 | 01 | WA | L&I PROVIDER NUMBER | OTHER |