Provider Demographics
NPI:1801024799
Name:HORN, KEVIN DALE (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DALE
Last Name:HORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N FANT ST
Mailing Address - Street 2:ACCOUNTING DEPARTMENT, ATTN: SHELIA WYATT
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-2751
Mailing Address - Fax:864-512-3719
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1335
Practice Address - Fax:864-512-8575
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018232207P00000X
SC1676207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPI #OtherBLUE CROSS & BLUE CHOICE
GA003138408AMedicaid
SC016761Medicaid
SC535117OtherUHC
SCP01277557OtherRAILROAD MEDICARE
SCNPI #OtherBLUE CROSS & BLUE CHOICE