1962401612 NPI number — DR. MICHAEL RAYMOND KEVERLINE MD

Table of Contents

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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