Healthcare Provider Details

I. General information

NPI: 1750313110
Provider Name (Legal Business Name): KEVIN M. RATHKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 CREEKSTONE DR
DURHAM NC
27703-9822
US

IV. Provider business mailing address

1540 SUNDAY DR
RALEIGH NC
27607-6000
US

V. Phone/Fax

Practice location:
  • Phone: 919-385-8880
  • Fax:
Mailing address:
  • Phone: 919-782-3456
  • Fax: 919-787-7552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2002-01621
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number01621
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier891329P
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: