MEDICARE: MS. MARY KATHERINE KUBACKI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1174968556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KATHERINE KUBACKI

Provider Business Mailing Address
First Line	:	5187 LOWELL BLVD
Second Line	:	APT #2
City	:	DENVER
State	:	CO
Zip	:	80221-1000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5187 LOWELL BLVD
Second Line	:	APT #2
City	:	DENVER
State	:	CO
Zip	:	80221-1000
Country	:	US
Telephone Number	:	630-234-0627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2013
Last Update Date	:	04/30/2013

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