Provider Demographics
NPI:1215196464
Name:CASSIDY, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:CASSIDY
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 1:1100 AVALON SQ
Mailing Address - Street 2:APT 1440
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2877
Mailing Address - Country:US
Mailing Address - Phone:516-723-9414
Mailing Address - Fax:
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5206
Practice Address - Country:US
Practice Address - Phone:516-627-8717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268962207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400104502Medicare PIN