MEDICARE: GEORGIA BLACKWOOD KUBIC M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	8406695-1205	UT

General Provider Information

NPI Number	:	1235429655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGIA BLACKWOOD KUBIC M.D.

Provider Business Mailing Address
First Line	:	2232 HAVERSHAM CLOSE
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1151
Country	:	US
Telephone Number	:	757-630-4046
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 CHIPETA WAY
Second Line	:	UNIVERSITY OF UTAH FAMILY MEDICINE RESIDENCY
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1260
Country	:	US
Telephone Number	:	801-587-3411
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	08/20/2014

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