Healthcare Provider Details

I. General information

NPI: 1962036558
Provider Name (Legal Business Name): KEVIN LEE HAIR NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PHIPPS LN
PARIS IL
61944-2919
US

IV. Provider business mailing address

10490 N US HIGHWAY 41
ROSEDALE IN
47874-9126
US

V. Phone/Fax

Practice location:
  • Phone: 217-463-4340
  • Fax:
Mailing address:
  • Phone: 812-249-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28167157A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209020837
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: