Basic Information
| Provider Information | |||||||||
| NPI: | 1992906382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUBEK | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473034988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776685621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1373 E SR 62 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128010840 | ||||||||
| FaxNumber: | 8128010024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 01078254A | IN | N | Allopathic & Osteopathic Physicians | Surgery | 208200000X | 01078254A | IN | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5778586 | 01 | IN | UHC | OTHER | 226996 | 01 | IN | SIHO | OTHER | 7100469740 | 05 | KY | MEDICAID | 50126138 | 01 | KY | KY PASSPORT | OTHER | 1075366 | 01 | IN | ANTHEM | OTHER | 4384232 | 01 | IN | AETNA | OTHER | 300001450 | 05 | IN | MEDICAID |