Provider Demographics
NPI:1760537633
Name:KUBERG, HARRY WILLI (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:WILLI
Last Name:KUBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1224
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1224
Mailing Address - Country:US
Mailing Address - Phone:256-331-9408
Mailing Address - Fax:256-331-9530
Practice Address - Street 1:15225 HIGHWAY 43 STE F
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1969
Practice Address - Country:US
Practice Address - Phone:256-331-9408
Practice Address - Fax:256-331-9530
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-98259OtherBLUECROSS BLUESHIELD
AL009935340Medicaid
ALH25827Medicare UPIN
AL009935340Medicaid