Healthcare Provider Details

I. General information

NPI: 1124295993
Provider Name (Legal Business Name): KEVIN C FILLMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W STATE ST
DOYLESTOWN PA
18901-2554
US

IV. Provider business mailing address

PO BOX 830624
PHILADELPHIA PA
19182-0624
US

V. Phone/Fax

Practice location:
  • Phone: 215-345-2290
  • Fax: 215-345-2596
Mailing address:
  • Phone: 800-666-1816
  • Fax: 706-653-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD433621
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier102139479-0001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: