Provider Demographics
NPI:1629024583
Name:MCBRIDE, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:MCBRIDE
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:1175 WILSON AVE NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-3493
Practice Address - Country:US
Practice Address - Phone:616-685-8650
Practice Address - Fax:616-791-2160
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3522386Medicaid
MI4179102Medicaid
MI4175810Medicaid
MI4115508Medicaid
MI4876940Medicaid
MI4162366Medicaid
MI3522386Medicaid
MI4179102Medicaid
MI4115508Medicaid
MIF06100Medicare UPIN