Provider Demographics
NPI:1649271990
Name:KIANOOSH KAVEH DO PA
Entity type:Organization
Organization Name:KIANOOSH KAVEH DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIANOOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVEH
Authorized Official - Suffix:
Authorized Official - Credentials:DO PA
Authorized Official - Phone:941-505-8720
Mailing Address - Street 1:3221 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8002
Mailing Address - Country:US
Mailing Address - Phone:941-505-8720
Mailing Address - Fax:941-505-8747
Practice Address - Street 1:3221 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8002
Practice Address - Country:US
Practice Address - Phone:941-505-8720
Practice Address - Fax:941-505-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8229207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2142967000OtherAMERIHEALTH
PA2148967000OtherINDEPENDENCE BC PA
FL2985402OtherAETNA BLUE BELL
FL24133OtherBCBS FL GRP NUMBER
471501OtherTUFTS
FL651256OtherCOMBINED INS
FL0323474OtherCIGNA
FL30030181OtherKEYSTONE MERCY HEALTH
FLN279248Medicaid
001457915OtherBCBS HIGHMARK
FL9814293OtherAETNA
FL265580200Medicaid
MA0000ZCY746OtherBCBS MASS
7405063OtherMAMSI INS
KKA150339OtherBCBS EXCELLUS NY
FL24133OtherBCBS FL GRP NUMBER
FL0323474OtherCIGNA
FL2142967000OtherAMERIHEALTH
FLE5536Medicare ID - Type UnspecifiedOLD MEDICARE PROVIDER #
KKA150339OtherBCBS EXCELLUS NY
FL24133OtherBCBS FL GRP NUMBER