1326099136 NPI number — DR. KENNETH L UBBEN M.D.

Table of content: DR. KENNETH L UBBEN M.D. (NPI 1326099136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326099136 NPI number — DR. KENNETH L UBBEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UBBEN
Provider First Name:
KENNETH
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326099136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 CUNNINGHAM COR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLA VISTA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72714-3520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-855-1247
Provider Business Mailing Address Fax Number:
479-855-1249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 CUNNINGHAM COR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLA VISTA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72714-3520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-855-1247
Provider Business Practice Location Address Fax Number:
479-855-1249
Provider Enumeration Date:
05/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  C-8212 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 122172001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".