Healthcare Provider Details

I. General information

NPI: 1750314811
Provider Name (Legal Business Name): KRZYSZTOF J KUBICKI, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FIRST AVE
CHESTER WV
26034
US

IV. Provider business mailing address

PO BOX 2407
WEIRTON WV
26062-1607
US

V. Phone/Fax

Practice location:
  • Phone: 304-387-2761
  • Fax:
Mailing address:
  • Phone: 304-387-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17474
License Number StateWV

VIII. Authorized Official

Name: DR. KRZYSZTOF J KUBICKI
Title or Position: OWNER
Credential: MD
Phone: 304-387-2761