MEDICARE: DR. KEVIN LOUIS PETERMANN M.D.

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	202K00000X	Phlebology Physician	036141794	IL
2	207R00000X	Internal Medicine Physician	232845	NY
3	207R00000X	Internal Medicine Physician	ME118086	FL
4	207R00000X	Internal Medicine Physician	036141794	IL

General Provider Information

NPI Number	:	1588744650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN LOUIS PETERMANN M.D.

Provider Business Mailing Address
First Line	:	3820 NORTHDALE BLVD STE 201
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-1893
Country	:	US
Telephone Number	:	813-961-1331
Fax Number	:	888-850-8316

Provider Business Practice Location Address
First Line	:	4700 W 95TH ST STE 303
Second Line	:
City	:	OAK LAWN
State	:	IL
Zip	:	60453-2572
Country	:	US
Telephone Number	:	800-991-6117
Fax Number	:	888-812-8191

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

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	02/15/2025

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