Provider Demographics
NPI:1427007616
Name:VERVERELI, KATHLEEN O (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:O
Last Name:VERVERELI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ELK CHASE CT STE 103
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-7260
Mailing Address - Country:US
Mailing Address - Phone:610-442-8585
Mailing Address - Fax:
Practice Address - Street 1:400 ELK CHASE CT
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071-7260
Practice Address - Country:US
Practice Address - Phone:610-442-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53463207K00000X
PAMD044795L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015088700005Medicaid
F99432Medicare UPIN
PA623953Medicare ID - Type Unspecified