Provider Demographics
NPI:1134421639
Name:DR RUSSELL KUBYCHECK SC
Entity type:Organization
Organization Name:DR RUSSELL KUBYCHECK SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:KUBYCHECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-789-0400
Mailing Address - Street 1:333 CHESTNUT STREET
Mailing Address - Street 2:#207
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521
Mailing Address - Country:US
Mailing Address - Phone:630-789-0400
Mailing Address - Fax:630-789-1504
Practice Address - Street 1:333 CHESTNUT STREET
Practice Address - Street 2:#207
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-789-0400
Practice Address - Fax:630-789-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-056399207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056399Medicaid
ILC44444Medicare UPIN