MEDICARE: MR. KEVIN MICHAEL FORDELL P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	4295	AZ
2	207P00000X	Emergency Medicine Physician	4295	AZ

General Provider Information

NPI Number	:	1417107822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN MICHAEL FORDELL P.A.

Provider Business Mailing Address
First Line	:	645 E MISSOURI AVE STE 300
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-1351
Country	:	US
Telephone Number	:	602-502-4621
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 N THUNDERBIRD CIR STE 303
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85215-1219
Country	:	US
Telephone Number	:	480-924-8382
Fax Number	:	480-924-8399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	03/01/2023

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