Healthcare Provider Details

I. General information

NPI: 1750449286
Provider Name (Legal Business Name): MARILYN ANN KUBICHEK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 COLUMBIA TPKE SUITE 109
FLORHAM PARK NJ
07932-1209
US

IV. Provider business mailing address

PO BOX 564
CHATHAM NJ
07928-0564
US

V. Phone/Fax

Practice location:
  • Phone: 973-377-7822
  • Fax: 973-377-7821
Mailing address:
  • Phone: 973-377-7822
  • Fax: 973-377-7821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number25MA06067000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number25MA06067000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: