1962401612 NPI number — DR. MICHAEL RAYMOND KEVERLINE MD

Table of content: (NPI 1134829062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962401612 NPI number — DR. MICHAEL RAYMOND KEVERLINE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEVERLINE
Provider First Name:
MICHAEL
Provider Middle Name:
RAYMOND
Provider Name Prefix Text:
DR.
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:
KEVERLINE
Provider Other First Name:
MICHAEL
Provider Other Middle Name:
RAYMOND
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962401612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3206 CHURCHLAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23321-5206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-484-0101
Provider Business Mailing Address Fax Number:
757-484-0515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3206 CHURCHLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23321-5206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-484-0101
Provider Business Practice Location Address Fax Number:
757-484-0515
Provider Enumeration Date:
07/15/2005

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: 207W00000X , with the licence number:  0101230614 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 7010360 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 8906674 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010080371 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4773409 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 29717 . This is a "OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 102064 . This is a "ANTHEM BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 2174956 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 399105 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 7827286 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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