Provider Demographics
NPI:1750314811
Name:KRZYSZTOF J KUBICKI, MD
Entity type:Organization
Organization Name:KRZYSZTOF J KUBICKI, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRZYSZTOF
Authorized Official - Middle Name:J
Authorized Official - Last Name:KUBICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-387-2761
Mailing Address - Street 1:PO BOX 2407
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-1607
Mailing Address - Country:US
Mailing Address - Phone:304-387-2761
Mailing Address - Fax:
Practice Address - Street 1:111 FIRST AVE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:WV
Practice Address - Zip Code:26034
Practice Address - Country:US
Practice Address - Phone:304-387-2761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17474207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006572Medicaid
WV9362521Medicare PIN
OH9362531Medicare PIN
WVPA15654Medicare PIN
F69129Medicare UPIN