Provider Demographics
NPI:1194724260
Name:RADECKI, KEVIN M (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:RADECKI
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:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-0650
Mailing Address - Country:US
Mailing Address - Phone:614-234-7505
Mailing Address - Fax:614-234-7506
Practice Address - Street 1:5965 E BROAD ST
Practice Address - Street 2:SUITE 340
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1562
Practice Address - Country:US
Practice Address - Phone:614-234-7505
Practice Address - Fax:614-234-7506
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-04-24
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
MDD0063316208G00000X
OH35079805208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD470P909GMedicare PIN
H39610Medicare UPIN
OHRA4226981Medicare PIN