Provider Demographics
NPI:1275680258
Name:KUBACKI, GENE MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:MICHAEL
Last Name:KUBACKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2932 W LUDWIG RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-1328
Mailing Address - Country:US
Mailing Address - Phone:260-755-1304
Mailing Address - Fax:260-755-1306
Practice Address - Street 1:1029 EAST 130TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:773-995-6300
Practice Address - Fax:601-376-2114
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16884207Q00000X
IL036098945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04009076Medicaid
IL036098945Medicaid
MS04009076Medicaid