Healthcare Provider Details

I. General information

NPI: 1225674310
Provider Name (Legal Business Name): KEVIN FITZGERALD BRIDEWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

90 CREEKWOOD DR UNIT 2
WILDER KY
41071-3348
US

V. Phone/Fax

Practice location:
  • Phone: 513-584-1000
  • Fax:
Mailing address:
  • Phone: 859-653-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: