Provider Demographics
NPI:1245415397
Name:HICKEY, KEVIN LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:HICKEY
Suffix:
Gender:M
Credentials:CRNA
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 12749
Mailing Address - Street 2:INDEPENDENT ANESTHESIOLOGISTS PSC
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41012-0749
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:ONE MEDICAL VILLAGE DRIVE
Practice Address - Street 2:INDEPENDENT ANESTHESIOLOGISTS PSC
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1090399163W00000X
OH262060163W00000X
KY079098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2833812Medicaid
KY7100032860Medicaid
IN200890500Medicaid
9492557OtherPHCS
000000547667OtherANTHEM
9492557OtherPHCS
IN200890500Medicaid
P00463791Medicare PIN
IN200890500Medicaid