Provider Demographics
NPI:1073700019
Name:HARRELD, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:L
Last Name:HARRELD
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 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-363-0588
Mailing Address - Fax:502-363-0972
Practice Address - Street 1:4402 CHURCHMAN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1190
Practice Address - Country:US
Practice Address - Phone:502-363-0588
Practice Address - Fax:502-363-0972
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105941207X00000X
KY44601207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0018911600Medicaid
FL147QSOtherBCBS
KY7100192290Medicaid
KY7100192290Medicaid
FLD1532ZMedicare PIN
NC52277BMedicare UPIN
KYP00969810Medicare PIN