Healthcare Provider Details

I. General information

NPI: 1225018294
Provider Name (Legal Business Name): KEVIN R MCCONNELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARTHA JEFFERSON DR FL 5
CHARLOTTESVILLE VA
22911
US

IV. Provider business mailing address

PO BOX 79777
BALTIMORE MD
21279-0777
US

V. Phone/Fax

Practice location:
  • Phone: 434-654-5260
  • Fax: 434-654-5261
Mailing address:
  • Phone: 434-654-7794
  • Fax: 434-654-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0101056567
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: