Provider Demographics
NPI:1639170723
Name:HITES, KEVIN MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:HITES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6720 GRELOT ROAD SUITE A
Mailing Address - Street 2:BUILDING 1 SUITE 1B
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-2676
Mailing Address - Country:US
Mailing Address - Phone:251-633-5155
Mailing Address - Fax:251-633-4508
Practice Address - Street 1:6720 GRELOT ROAD SUITE A
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-2676
Practice Address - Country:US
Practice Address - Phone:251-633-5155
Practice Address - Fax:251-633-4508
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108726363A00000X
ALPA.255363A00000X, 207P00000X
ALPA225363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51181661OtherBCBS AL
AL51181661OtherBCBS AL
AL102I973550Medicare PIN
AL51145264OtherBLUE CROSS BLUE SHIELD OF AL
AL1639170723OtherTRICARE SOUTH
AL511-01662OtherBCBS
AL511-01660OtherBCBS
AL511-01663OtherBCBS
ALP21791Medicare UPIN
AL051503556Medicare ID - Type Unspecified
AL116514Medicaid
AL116516Medicaid