Provider Demographics
NPI:1477043859
Name:BIRD, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BIRD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8751 JAFFA COURT EAST DR APT 11
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2398
Mailing Address - Country:US
Mailing Address - Phone:317-308-0644
Mailing Address - Fax:
Practice Address - Street 1:493 WESTFIELD RD STE A
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1304
Practice Address - Country:US
Practice Address - Phone:317-770-4100
Practice Address - Fax:317-770-4105
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002542A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017857Medicaid