Provider Demographics
NPI:1154398618
Name:KILLEEN, KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KILLEEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-4109
Mailing Address - Country:US
Mailing Address - Phone:413-881-5427
Mailing Address - Fax:413-496-6836
Practice Address - Street 1:77 HOSPITAL AVENUE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-662-2486
Practice Address - Fax:413-662-2102
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8935208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHAA37880OtherHAVARD PILGRIM HEALTHCARE
NH0109136Y0NH01OtherBLUE CROSS/BLUE SHIELD
NH24P100OtherMVP
NH30008498Medicaid
VT28550OtherBLUE CROSS/BLUE SHIELD
VTORE2655Medicaid
NHB91339Medicare UPIN
NH30008498Medicaid
NHRE2655Medicare ID - Type Unspecified