Provider Demographics
NPI:1386660355
Name:KUBE, BRENDA A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:A
Last Name:KUBE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3649
Practice Address - Street 1:911 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:IL
Practice Address - Zip Code:61752-1894
Practice Address - Country:US
Practice Address - Phone:309-962-2081
Practice Address - Fax:309-962-9021
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5315769OtherBLUE CROSS BLUE SHIELD
H40596Medicare UPIN
IL374440Medicare ID - Type UnspecifiedMEDICARE GROUP SCM
P00078778Medicare PIN
IL748940Medicare ID - Type UnspecifiedMEDICARE GROUP HPT
IL206706Medicare ID - Type UnspecifiedMEDICARE GROUP LFM
K00502Medicare ID - Type Unspecified