Provider Demographics
NPI:1649029364
Name:ADDISON, KEVIN (ATC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:ADDISON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 ARGYLE AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-4561
Mailing Address - Country:US
Mailing Address - Phone:803-467-9652
Mailing Address - Fax:
Practice Address - Street 1:1800 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-3302
Practice Address - Country:US
Practice Address - Phone:215-204-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer