Provider Demographics
NPI:1073514238
Name:HARRISON, KEVIN CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CHARLES
Last Name:HARRISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9460 AMBERDALE DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236
Mailing Address - Country:US
Mailing Address - Phone:804-276-2470
Mailing Address - Fax:804-276-2473
Practice Address - Street 1:9460 AMBERDALE DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23236
Practice Address - Country:US
Practice Address - Phone:804-276-2470
Practice Address - Fax:804-276-2473
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102201098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA142999OtherANTHEM PROVEDIER #
VA142999OtherANTHEM PROVEDIER #
H13244Medicare UPIN
VA00W028K01Medicare PIN