Healthcare Provider Details

I. General information

NPI: 1033201033
Provider Name (Legal Business Name): KEVIN R LUSK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S MAIN ST
FERDINAND IN
47532-9534
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-367-1906
  • Fax: 812-367-2487
Mailing address:
  • Phone: 812-996-0410
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01048988A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: