MEDICARE: KEVIN RICHARD DMYTRIW MD

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	33539	NJ

General Provider Information

NPI Number	:	1598768038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN RICHARD DMYTRIW MD

Provider Business Mailing Address
First Line	:	524 SOUTHPARK BOULEVARD
Second Line	:	JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834
Country	:	US
Telephone Number	:	804-504-7980
Fax Number	:	804-504-7991

Provider Business Practice Location Address
First Line	:	524 SOUTHPARK BOULEVARD
Second Line	:	JENCARE NEIGHBORHOOD MEDICAL SOUTH PARK, LLC
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834
Country	:	US
Telephone Number	:	804-504-7980
Fax Number	:	804-504-7991

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

Provider Enumeration Date	:	05/28/2005
Last Update Date	:	08/14/2014

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