Provider Demographics
NPI:1407972862
Name:E J KUEBECK MD INC
Entity Type:Organization
Organization Name:E J KUEBECK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDELBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUEBECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-354-3921
Mailing Address - Street 1:1052 W WOOSTER ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402
Mailing Address - Country:US
Mailing Address - Phone:419-354-3921
Mailing Address - Fax:419-354-3001
Practice Address - Street 1:1052 W WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402
Practice Address - Country:US
Practice Address - Phone:419-354-3921
Practice Address - Fax:419-354-3001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045108K207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0516427Medicaid
OHA80153Medicare UPIN
OH9327611Medicare PIN