Provider Demographics
NPI:1124295993
Name:FILLMORE, KEVIN C (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 830624
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0624
Mailing Address - Country:US
Mailing Address - Phone:800-666-1816
Mailing Address - Fax:706-653-0615
Practice Address - Street 1:595 W STATE ST
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2554
Practice Address - Country:US
Practice Address - Phone:215-345-2290
Practice Address - Fax:215-345-2596
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4336212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102139479-0001Medicaid
PA125463GG5Medicare PIN