=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174740245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN ERIC BUCK D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 09/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 189 OUTER LOOP SUITE 2
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40214-5544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-379-8870
-----------------------------------------------------
Fax | 502-394-3600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 776351
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60677-6351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-588-9490
-----------------------------------------------------
Fax | 502-272-5116
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 03137
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------