Provider Demographics
NPI:1669460861
Name:CLEARY, KEVIN T (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:CLEARY
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 5661
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-5661
Mailing Address - Country:US
Mailing Address - Phone:706-354-5770
Mailing Address - Fax:706-354-5769
Practice Address - Street 1:60 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1210
Practice Address - Country:US
Practice Address - Phone:800-532-6151
Practice Address - Fax:770-251-7873
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052263207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA651957808EMedicaid
GA93BBGGHMedicare ID - Type Unspecified
GAP00091077Medicare ID - Type UnspecifiedRAILROAD MEDICARE
GA651957808EMedicaid