Healthcare Provider Details

I. General information

NPI: 1942447032
Provider Name (Legal Business Name): KEVIN ANDREW MODESTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 03/06/2024
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PEACEHEALTH SURGICAL SPECIALITIES 3355 RIVERBEND DR., SUITE 300
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

PEACEHEALTH SURGICAL SPECIALITIES 3355 RIVERBEND DR., SUITE 300
SPRINGFIELD OR
97477
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-8333
  • Fax: 541-222-8320
Mailing address:
  • Phone: 541-222-8333
  • Fax: 541-222-8320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD157808
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD157808
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: