Provider Demographics
NPI:1821037532
Name:KUBLEY, ROD STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:ROD
Middle Name:STEPHEN
Last Name:KUBLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8700
Mailing Address - Fax:574-335-0760
Practice Address - Street 1:1919 LAKE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-941-2929
Practice Address - Fax:574-941-3008
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN021236800OtherFEDERAL BLACK LUNG PIN
IN100173750BMedicaid
IN000000216243OtherBCBS
IN187610AMedicare PIN
IN187730018Medicare PIN
IN100173750BMedicaid
IN080178366Medicare PIN