Healthcare Provider Details

I. General information

NPI: 1396879284
Provider Name (Legal Business Name): ALEXANDER M. GUBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6569 N CHARLES ST SUITE 707
BALTIMORE MD
21204-6831
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5741
US

V. Phone/Fax

Practice location:
  • Phone: 410-821-8181
  • Fax: 410-821-0790
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberD0016496
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number18328
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number39832
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number71689
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: