Provider Demographics
NPI:1104819812
Name:HESSE, KEVIN M (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:HESSE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-0930
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:4020 RAINTREE RD
Practice Address - Street 2:SUITE D
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3749
Practice Address - Country:US
Practice Address - Phone:757-484-4241
Practice Address - Fax:757-484-4487
Is Sole Proprietor?:No
Enumeration Date:2005-08-27
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017353-1225100000X
VA2305210751225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1104819812Medicaid
Q56530AOtherMEDICARE PTAN
VA1104819812Medicaid