Healthcare Provider Details

I. General information

NPI: 1497012488
Provider Name (Legal Business Name): KEVIN M PHELAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MDG, UNIT 2060
APO AP
96278
US

IV. Provider business mailing address

900 23RD ST NW
WASHINGTON DC
20037-2342
US

V. Phone/Fax

Practice location:
  • Phone: 505-784-8717
  • Fax:
Mailing address:
  • Phone: 202-677-6219
  • Fax: 202-741-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD210001446
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125.062147
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: