1063414514 NPI number — KEVIN G LAX MD

Table of content: KEVIN G LAX MD (NPI 1063414514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063414514 NPI number — KEVIN G LAX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAX
Provider First Name:
KEVIN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1063414514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
595 W STATE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOYLESTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18901-2554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-933-0259
Provider Business Mailing Address Fax Number:
215-933-3672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 HUNTINGDON PIKE
Provider Second Line Business Practice Location Address:
SUITE 252
Provider Business Practice Location Address City Name:
MEADOWBROOK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19046-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-938-1550
Provider Business Practice Location Address Fax Number:
215-938-1342
Provider Enumeration Date:
08/15/2005

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: 207RC0000X , with the licence number:  MD-061973L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: MD061973L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0016624120002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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