Healthcare Provider Details

I. General information

NPI: 1497830582
Provider Name (Legal Business Name): KEVIN C. DYSART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD CHILDREN'S HOSPITAL OF PHILADELPHIA - NEONATOLOGY
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

100 E PENN SQ 9TH FLOOR
PHILADELPHIA PA
19107-3323
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1944
  • Fax: 215-590-4454
Mailing address:
  • Phone: 267-425-9234
  • Fax: 267-425-9299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD417610
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: