Provider Demographics
NPI:1073577383
Name:KIST, KEVIN WILLIAM JR (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:KIST
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 HIGH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3100
Practice Address - Country:US
Practice Address - Phone:570-321-3580
Practice Address - Fax:570-321-3581
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006496L207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE62166OtherHEALTHAMERICA
PA11451OtherGEISINGER HEALTH PLAN
PA1553605OtherUNITEDHEALTHCARE
PA746215OtherHIGHMARK BLUE SHIELD
PA0014113140004Medicaid
PA5800429OtherAETNA
PA820729OtherFIRST PRIORITY HEALTH
PAE62166OtherHEALTHAMERICA
PA746215OtherHIGHMARK BLUE SHIELD
PA0014113140004Medicaid