Healthcare Provider Details

I. General information

NPI: 1518994870
Provider Name (Legal Business Name): GERALD MARK KUBIK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MAPLE LN STE 1
ASHLAND WI
54806-3610
US

IV. Provider business mailing address

1615 MAPLE LN STE 1
ASHLAND WI
54806-3610
US

V. Phone/Fax

Practice location:
  • Phone: 715-685-7500
  • Fax: 715-682-2481
Mailing address:
  • Phone: 715-685-7500
  • Fax: 715-682-2481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36849-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: