1689669715 NPI number — KEVIN M SMALL MD

Table of content: KEVIN M SMALL MD (NPI 1689669715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689669715 NPI number — KEVIN M SMALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALL
Provider First Name:
KEVIN
Provider Middle Name:
M
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:
1689669715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 N NILES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1610
Provider Business Mailing Address Fax Number:
574-237-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 MEMORIAL DR STE 312
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-647-5200
Provider Business Practice Location Address Fax Number:
574-647-5210
Provider Enumeration Date:
09/14/2005

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: 2085R0204X , with the licence number:  01044597A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200181930 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com