Basic Information
| Provider Information | |||||||||
| NPI: | 1982677761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUBIN | ||||||||
| FirstName: | GERRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
| Address2: | SUITE101 | ||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117763456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315748354 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Practice Location | |||||||||
| Address1: | 180 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117068427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6316752001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 177178 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 02023150 | 05 | NY | MEDICAID |