Provider Demographics
NPI:1841249125
Name:GLEESON, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GLEESON
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 1:1512 E CARACAS AVE
Mailing Address - Street 2:400
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-1184
Mailing Address - Country:US
Mailing Address - Phone:717-312-1441
Mailing Address - Fax:717-312-0441
Practice Address - Street 1:1512 E CARACAS AVE
Practice Address - Street 2:400
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-1184
Practice Address - Country:US
Practice Address - Phone:717-312-1441
Practice Address - Fax:717-312-0441
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031276E207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA158519Medicaid
PA158519Medicare ID - Type Unspecified
PA158519Medicaid