Provider Demographics
NPI:1770719577
Name:J P MCCUBBIN MD PLLC
Entity type:Organization
Organization Name:J P MCCUBBIN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCUBBIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-742-9164
Mailing Address - Street 1:4519 WOLFCREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-5501
Mailing Address - Country:US
Mailing Address - Phone:502-742-9164
Mailing Address - Fax:502-742-9395
Practice Address - Street 1:4519 WOLFCREEK PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-5501
Practice Address - Country:US
Practice Address - Phone:502-742-9164
Practice Address - Fax:502-742-9395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100072840Medicaid
KY01066Medicare PIN