Provider Demographics
NPI:1346201191
Name:MCCANN, KEVIN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
Last Name:MCCANN
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 1:4600 ROUTE 152
Mailing Address - Street 2:
Mailing Address - City:LAVALETTE
Mailing Address - State:WV
Mailing Address - Zip Code:25535-9702
Mailing Address - Country:US
Mailing Address - Phone:304-697-9480
Mailing Address - Fax:304-697-9491
Practice Address - Street 1:4600 ROUTE 152
Practice Address - Street 2:
Practice Address - City:LAVALETTE
Practice Address - State:WV
Practice Address - Zip Code:25535-9702
Practice Address - Country:US
Practice Address - Phone:304-697-9480
Practice Address - Fax:304-697-9491
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0047641000Medicaid
KY64942063Medicaid
OH2016179Medicaid
KY64942063Medicaid
WV0047641000Medicaid