Healthcare Provider Details

I. General information

NPI: 1114172004
Provider Name (Legal Business Name): KEVIN P BOYD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE PEDIATRIC RADIOLOGY
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

9000 W WISCONSIN AVE PEDIATRIC RADIOLOGY
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-805-3666
  • Fax: 414-266-8666
Mailing address:
  • Phone: 414-805-3666
  • Fax: 414-266-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number57215
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number036.127452
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: