MEDICARE: KEVIN MICHAEL DONOVAN L.M.T.

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	225700000X	Massage Therapist	MA 44336	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C3954	OTHER	FL	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1699898098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN MICHAEL DONOVAN L.M.T.

Provider Business Mailing Address
First Line	:	4932 BEACH DR
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32408-6801
Country	:	US
Telephone Number	:	850-596-5621
Fax Number	:

Provider Business Practice Location Address
First Line	:	12115 PANAMA CITY BEACH PKWY
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-2609
Country	:	US
Telephone Number	:	850-236-5664
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	07/08/2007

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