MEDICARE: DR. KEVIN JAMES CUCCINELLI 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	207Q00000X	Family Medicine Physician	DR.0042299	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	DR.0042299	OTHER	CO	CO LICENSE NUMBER

General Provider Information

NPI Number	:	1770553794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN JAMES CUCCINELLI MD

Provider Business Mailing Address
First Line	:	1001 E JOHNSON ST
Second Line	:
City	:	HOLYOKE
State	:	CO
Zip	:	80734-1854
Country	:	US
Telephone Number	:	970-854-2241
Fax Number	:	970-458-4581

Provider Business Practice Location Address
First Line	:	1001 E JOHNSON ST
Second Line	:
City	:	HOLYOKE
State	:	CO
Zip	:	80734-1854
Country	:	US
Telephone Number	:	970-854-2241
Fax Number	:	970-458-4581

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	02/10/2021

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