Provider Demographics
NPI:1780789461
Name:KUMMEROW, KEVIN ALDEN (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ALDEN
Last Name:KUMMEROW
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 1:1369 SPECTACLE LAKE LN
Mailing Address - Street 2:
Mailing Address - City:PHELPS
Mailing Address - State:WI
Mailing Address - Zip Code:54554-9453
Mailing Address - Country:US
Mailing Address - Phone:715-545-4078
Mailing Address - Fax:
Practice Address - Street 1:629 W CLOVERLAND DR
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1006
Practice Address - Country:US
Practice Address - Phone:906-932-0032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine