Provider Demographics
NPI:1932396942
Name:KEVIN T OCONNOR DO PC
Entity Type:Organization
Organization Name:KEVIN T OCONNOR DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:989-584-6801
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48811-0326
Mailing Address - Country:US
Mailing Address - Phone:989-584-6801
Mailing Address - Fax:
Practice Address - Street 1:421 S BALDWIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-2102
Practice Address - Country:US
Practice Address - Phone:989-584-6801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010639208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3526975Medicaid
MI0255900344OtherBLUE CROSS BLUE SHIELD
MI0255900344OtherBLUE CROSS BLUE SHIELD
MI0P31430Medicare PIN