Provider Demographics
NPI:1275546905
Name:PASSERBY, KEVIN A (MPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:PASSERBY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1713
Mailing Address - Country:US
Mailing Address - Phone:304-329-1818
Mailing Address - Fax:304-329-1819
Practice Address - Street 1:557 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1713
Practice Address - Country:US
Practice Address - Phone:304-329-1818
Practice Address - Fax:304-329-1819
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001135225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV156572000Medicaid
OH2701802Medicaid
OH2701802Medicaid