Provider Demographics
NPI:1609872811
Name:KRUSE, KEVIN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:KRUSE
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PARK DR
Practice Address - Street 2:STE 210
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2948
Practice Address - Country:US
Practice Address - Phone:704-403-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600141207R00000X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
74730OtherPARTNERS
NC50380OtherBLUE CROSS BLUE SHIELD
SCQ0014JMedicaid
561845661OtherCHAMPUS
NC8950380Medicaid
63797OtherMAMSI
NC1609872811Medicaid
4971OtherAETNA
NC2222183CMedicare PIN
SCQ0014JMedicaid
561845661OtherCHAMPUS
NC2222183DMedicare PIN
G25501Medicare UPIN