Provider Demographics
NPI:1356332977
Name:MCAWARD, KEVIN JEREMY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JEREMY
Last Name:MCAWARD
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 1:3355 DOUGLAS RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 W JEFFERSON BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1994
Practice Address - Country:US
Practice Address - Phone:574-647-1669
Practice Address - Fax:574-239-6461
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058339A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200464680Medicaid
IN941030GGGGMedicare ID - Type UnspecifiedRENDERING (ER)
IN233530BMedicare PIN
IN162520XXMedicare PIN
IN200464680Medicaid