Provider Demographics
NPI:1932108206
Name:KEVAK, RUDOLPH MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:MICHAEL
Last Name:KEVAK
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 1:200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177-2802
Mailing Address - Country:US
Mailing Address - Phone:304-201-3600
Mailing Address - Fax:304-201-2368
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177-2802
Practice Address - Country:US
Practice Address - Phone:304-201-3600
Practice Address - Fax:304-201-2368
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18988207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5600010-000Medicaid
KE7257301Medicare ID - Type Unspecified
WV5600010-000Medicaid