Provider Demographics
NPI:1326049412
Name:SUPPLE, KEVIN M (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:SUPPLE
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:PO BOX 38008
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27438-8008
Mailing Address - Country:US
Mailing Address - Phone:336-545-5000
Mailing Address - Fax:336-545-5020
Practice Address - Street 1:3200 NORTHLINE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7616
Practice Address - Country:US
Practice Address - Phone:336-545-5000
Practice Address - Fax:336-545-5020
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC36604174400000X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8981007Medicaid
NC2185077Medicare PIN
NC0198770001Medicare NSC
NCF54311Medicare UPIN