Provider Demographics
NPI:1245291657
Name:WALSH, KEVIN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:931 E HAVERFORD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3838
Mailing Address - Country:US
Mailing Address - Phone:610-520-6170
Mailing Address - Fax:610-520-6174
Practice Address - Street 1:931 E HAVERFORD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3838
Practice Address - Country:US
Practice Address - Phone:610-520-6170
Practice Address - Fax:610-520-6174
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD074337207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAH66662Medicare UPIN
PA059842Medicare ID - Type Unspecified