Provider Demographics
NPI:1780687954
Name:PURVIS, HENRY KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:KEVIN
Last Name:PURVIS
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 1:658 NORTHSIDE DR E
Mailing Address - Street 2:STE A
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4828
Mailing Address - Country:US
Mailing Address - Phone:912-764-9684
Mailing Address - Fax:912-489-8676
Practice Address - Street 1:658 NORTHSIDE DR E
Practice Address - Street 2:STE A
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4828
Practice Address - Country:US
Practice Address - Phone:912-764-9684
Practice Address - Fax:912-489-8676
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA342225OtherWELLCARE
GA00868645AMedicaid
GA10062308OtherAMERIGROUP
GA08BBTGWMedicare ID - Type Unspecified
GA080157472Medicare ID - Type UnspecifiedRRMC
GA10062308OtherAMERIGROUP