Provider Demographics
NPI:1720057714
Name:KULUBYA, PATRICK S (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:S
Last Name:KULUBYA
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 1:6490 MOUNT MORIAH ROAD EXT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-3729
Mailing Address - Country:US
Mailing Address - Phone:901-565-0244
Mailing Address - Fax:901-565-0616
Practice Address - Street 1:6490 MOUNT MORIAH ROAD EXT
Practice Address - Street 2:SUITE 200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3729
Practice Address - Country:US
Practice Address - Phone:901-565-0244
Practice Address - Fax:901-565-0616
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37342207RN0300X
ARE3707207RN0300X
MS18029207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4076411OtherBLUE CROSS BLUE SHIELD
AR5M560OtherBLUE CROSS BLUE SHIELD
MS07624752Medicaid
TN3889682Medicaid
AR150991001Medicaid
TN29502Medicaid
TN4076411OtherBLUE CROSS BLUE SHIELD
TNH14142Medicare UPIN
MS07624752Medicaid
TN29502Medicaid
MSH14142Medicare UPIN
ARH14142Medicare UPIN
MS390000139Medicare ID - Type Unspecified