Healthcare Provider Details

I. General information

NPI: 1114367067
Provider Name (Legal Business Name): FOUAD KUTUBY M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 CALUMET AVE STE 206
MUNSTER IN
46321-2546
US

IV. Provider business mailing address

PO BOX 1103
CROWN POINT IN
46308-1103
US

V. Phone/Fax

Practice location:
  • Phone: 718-710-8005
  • Fax:
Mailing address:
  • Phone: 219-662-3931
  • Fax: 219-663-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036140158
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01080676A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036.140158
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: