Provider Demographics
NPI:1104913680
Name:KEPHART, ERIC M (DO)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:KEPHART
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:100 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:FAIRLESS HILLS
Practice Address - State:PA
Practice Address - Zip Code:19030-1008
Practice Address - Country:US
Practice Address - Phone:267-587-0775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014338207QS0010X, 207Q00000X
PAOT011732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022699560002Medicaid
PA155937J30Medicare PIN