Healthcare Provider Details

I. General information

NPI: 1912926205
Provider Name (Legal Business Name): BRYAN W RUBACH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 OGDEN AVE STE 301
AURORA IL
60504-7205
US

IV. Provider business mailing address

2040 OGDEN AVE STE 301
AURORA IL
60504-7205
US

V. Phone/Fax

Practice location:
  • Phone: 630-978-6895
  • Fax: 630-375-2905
Mailing address:
  • Phone: 630-978-6895
  • Fax: 630-375-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number364032123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: