Provider Demographics
NPI:1104808294
Name:KING, KEVIN RICHARD (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:KING
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 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:706-494-3072
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:4401 RIVERCHASE DR
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-7483
Practice Address - Country:US
Practice Address - Phone:334-732-3000
Practice Address - Fax:706-494-3008
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056310208M00000X
AL42356208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA633050776EMedicaid
GA633050776Medicare PIN
GA511I080274Medicare PIN
GAGRP3627Medicare ID - Type Unspecified
088BSDQMedicare PIN