=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073977377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN MICHAEL LAMM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2016
-----------------------------------------------------
Last Update Date | 06/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 OLD MOCKSVILLE RD
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28625-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-878-2021
-----------------------------------------------------
Fax | 704-878-2022
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1845
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28687-1845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-873-4277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 2019-01185
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------