Provider Demographics
NPI:1386677896
Name:VAN VOORHIS, KERRY T (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:T
Last Name:VAN VOORHIS
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6010 CARNEGIE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-4637
Practice Address - Country:US
Practice Address - Phone:704-384-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1386677896Medicaid
NC89133PCMedicaid
SCQ56889Medicaid
NC133PCOtherNCBCBS
NC89133PCMedicaid
SCQ56889Medicaid
NC1386677896Medicaid
NC2012083AMedicare PIN
NC2012083Medicare PIN