Provider Demographics
NPI:1912920273
Name:LOBDELL, KEVIN WALLACE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WALLACE
Last Name:LOBDELL
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR
Practice Address - Street 2:STE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2963
Practice Address - Country:US
Practice Address - Phone:704-355-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400906208600000X, 2086S0102X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC137TQOtherNCBCBS
NC89137TQMedicaid
SCN06004Medicaid
NC2032397AMedicare PIN
NC137TQOtherNCBCBS
NC2032397BMedicare PIN
NCG59403Medicare UPIN