Provider Demographics
NPI:1205826567
Name:CARBONE, KEVIN (RPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CARBONE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:870 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2105
Practice Address - Country:US
Practice Address - Phone:413-734-7277
Practice Address - Fax:413-734-7879
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY68191OtherBLUECROSS/BLUESHIELD
MA0035587OtherNEIGHBORHOOD HEALTH PLAN
MA0322211Medicaid
MA043171699OtherCIGNA
MA704317OtherCONNECTICARE
MA0035587OtherNEIGHBORHOOD HEALTH PLAN