Provider Demographics
NPI:1760025613
Name:MCIVER, KYLE CECIL
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:CECIL
Last Name:MCIVER
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 1:395 EAST ST
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-1218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty