Provider Demographics
NPI:1902872831
Name:KAULBACK, KYLE R (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:R
Last Name:KAULBACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N WYOMISSING AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19607-1936
Mailing Address - Country:US
Mailing Address - Phone:570-621-5064
Mailing Address - Fax:
Practice Address - Street 1:252 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-6111
Practice Address - Country:US
Practice Address - Phone:717-270-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042359L207R00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F62755Medicare UPIN