Provider Demographics
NPI:1093797045
Name:MCMULLEN, KEVIN P (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:MCMULLEN
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:PO BOX 1828
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-1828
Mailing Address - Country:US
Mailing Address - Phone:704-878-4615
Mailing Address - Fax:704-878-7193
Practice Address - Street 1:2400 17TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5351
Practice Address - Country:US
Practice Address - Phone:812-376-5550
Practice Address - Fax:812-376-5930
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99009412085R0001X
IN01070320A2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000746372OtherANTHEM
IN000000990588OtherANTHEM PIN
NC802872OtherPARTNERS
NC891333UMedicaid
SCQ0094CMedicaid
NC1333UOtherBCBS
WV2004948000Medicaid
IN201037980Medicaid
7957688OtherAETNA
NCC6010OtherMEDCOST
VA10001251Medicaid
INP01420734OtherRAILROAD MEDICARE
INP01420734OtherRAILROAD MEDICARE
7957688OtherAETNA
NC1333UOtherBCBS
IN201037980Medicaid
WV2004948000Medicaid
INM400057338Medicare PIN