Provider Demographics
NPI:1508869124
Name:ZECHIN, KEVAN SCOTT SR (MD)
Entity Type:Individual
Prefix:
First Name:KEVAN
Middle Name:SCOTT
Last Name:ZECHIN
Suffix:SR
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 458
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-0458
Mailing Address - Country:US
Mailing Address - Phone:641-683-5773
Mailing Address - Fax:641-226-5759
Practice Address - Street 1:201 S MARKET ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2924
Practice Address - Country:US
Practice Address - Phone:641-683-5773
Practice Address - Fax:641-226-5759
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32842261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0221176Medicaid
IL421527584003Medicaid
33686OtherBLUE CROSS BLUE SHIELD
42152758410OtherJOHN DEERE
I7910Medicare ID - Type UnspecifiedMEDICARE B
H01056Medicare UPIN