Healthcare Provider Details

I. General information

NPI: 1093762999
Provider Name (Legal Business Name): ALBERT J DERUBERTIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W HOMER ST
MICHIGAN CITY IN
46360-4358
US

IV. Provider business mailing address

301 W HOMER ST
MICHIGAN CITY IN
46360-4358
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax:
Mailing address:
  • Phone: 219-879-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036081549
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number020-04394A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: