Provider Demographics
NPI:1295506103
Name:ANDERSON, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 W NIMISILA RD
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44216-8900
Mailing Address - Country:US
Mailing Address - Phone:234-281-6309
Mailing Address - Fax:
Practice Address - Street 1:1131 W NIMISILA RD
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44216-8900
Practice Address - Country:US
Practice Address - Phone:234-281-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004677175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist