Healthcare Provider Details

I. General information

NPI: 1104808294
Provider Name (Legal Business Name): KEVIN RICHARD KING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 RIVERCHASE DR
PHENIX CITY AL
36867-7483
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 334-732-3000
  • Fax: 706-494-3008
Mailing address:
  • Phone: 706-494-3072
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number056310
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number42356
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: