Healthcare Provider Details

I. General information

NPI: 1578008793
Provider Name (Legal Business Name): KEVIN M WHITMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date: 08/26/2021
Reactivation Date: 12/22/2021

III. Provider practice location address

75 BARRETT DR UNIT 115
WEBSTER NY
14580-7005
US

IV. Provider business mailing address

75 BARRETT DR UNIT 115
WEBSTER NY
14580-7005
US

V. Phone/Fax

Practice location:
  • Phone: 585-456-8394
  • Fax: 585-299-9825
Mailing address:
  • Phone: 585-456-8394
  • Fax: 585-299-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number447603
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMD-STUDENT
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: