Provider Demographics
NPI:1700949575
Name:KEVILL, KATHARINE
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:KEVILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HSC T 11 080 DEPT OF PEDIATRICS
Mailing Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8111
Mailing Address - Country:US
Mailing Address - Phone:631-444-8014
Mailing Address - Fax:
Practice Address - Street 1:HSC T 11 020 DEPT OF PEDIATRICS
Practice Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8111
Practice Address - Country:US
Practice Address - Phone:631-444-8014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01732207RP1001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
I46385Medicare ID - Type Unspecified
NC5902688Medicare ID - Type Unspecified
NC2048961Medicare ID - Type Unspecified