Provider Demographics
NPI:1114016813
Name:BAILEY, KEVIN R (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:BAILEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44223-1404
Mailing Address - Country:US
Mailing Address - Phone:330-971-7246
Mailing Address - Fax:330-971-7256
Practice Address - Street 1:1900 23RD ST
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-1404
Practice Address - Country:US
Practice Address - Phone:330-971-7246
Practice Address - Fax:330-971-7256
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074247Medicaid