Provider Demographics
NPI:1124011796
Name:CHARTRAND, KEVIN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:CHARTRAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13221 RAVENNA RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-9047
Mailing Address - Country:US
Mailing Address - Phone:440-286-7420
Mailing Address - Fax:440-286-6354
Practice Address - Street 1:13221 RAVENNA RD
Practice Address - Street 2:SUITE 9
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-9047
Practice Address - Country:US
Practice Address - Phone:440-286-7420
Practice Address - Fax:440-286-6354
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-5764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0678495Medicaid
OHA17732Medicare UPIN
OH0678495Medicaid
OH7012991Medicare PIN