Basic Information
| Provider Information | |||||||||
| NPI: | 1306822192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBEK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2993 | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301569170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707792184 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 MEDICAL WAY | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300782195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709790200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 037621 | GA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000560578G | 05 | GA | MEDICAID |