Provider Demographics
NPI:1063414514
Name:LAX, KEVIN G (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:LAX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:595 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-2554
Mailing Address - Country:US
Mailing Address - Phone:215-933-0259
Mailing Address - Fax:215-933-3672
Practice Address - Street 1:1650 HUNTINGDON PIKE
Practice Address - Street 2:SUITE 252
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8001
Practice Address - Country:US
Practice Address - Phone:215-938-1550
Practice Address - Fax:215-938-1342
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-061973L207RC0000X
PAMD061973L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016624120002Medicaid
PA907120Medicare PIN
F71346Medicare UPIN