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General NPI Number Information
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NPI Number | 1275680258
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Entity Type | Individual
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Provider Name | GENE MICHAEL KUBACKI DO
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Gender | Male
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Dates
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Enumeration Date | 01/04/2007
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Last Update Date | 12/16/2019
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Provider Practice Location Address
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Address Line | 1029 EAST 130TH STREET
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City | CHICAGO
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State | IL
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Zip | 60628
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Country | US
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Telephone | 773-995-6300
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Fax | 601-376-2114
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Provider Business Mailing Address
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Address Line | 2932 W LUDWIG RD
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City | FORT WAYNE
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State | IN
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Zip | 46818-1328
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Country | US
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Telephone | 260-755-1304
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Fax | 260-755-1306
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 16884
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036098945
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License Number State | IL
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