Provider Demographics
NPI:1952340903
Name:ACKLEY, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:ACKLEY
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 1:4415 AICHOLTZ ROAD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-5139
Mailing Address - Country:US
Mailing Address - Phone:513-752-9610
Mailing Address - Fax:513-732-8734
Practice Address - Street 1:4415 AICHOLTZ RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1506
Practice Address - Country:US
Practice Address - Phone:513-752-9610
Practice Address - Fax:513-732-8734
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18592207P00000X
OH35067544-A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0047437000Medicaid
OH0179168Medicaid
WV0047437000Medicaid
OHH051771Medicare PIN