Provider Demographics
NPI:1073505244
Name:FISHER, KEVIN ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:FISHER
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 1:2500 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4508
Mailing Address - Country:US
Mailing Address - Phone:814-838-9000
Mailing Address - Fax:814-838-0462
Practice Address - Street 1:2500 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4508
Practice Address - Country:US
Practice Address - Phone:814-838-9000
Practice Address - Fax:814-838-0462
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG490702085R0001X
PAMD4451612085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G490700Medicaid
PA102710446Medicaid
P00681332OtherRAILROAD MEDICARE
00G49070IMedicare PIN
PA102710446Medicaid