Provider Demographics
NPI:1427320266
Name:KEVIN J MASTERSON MD INC
Entity type:Organization
Organization Name:KEVIN J MASTERSON MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-356-5477
Mailing Address - Street 1:20455 LORAIN RD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3529
Mailing Address - Country:US
Mailing Address - Phone:440-356-5477
Mailing Address - Fax:440-356-5885
Practice Address - Street 1:20455 LORAIN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3529
Practice Address - Country:US
Practice Address - Phone:440-356-5477
Practice Address - Fax:440-356-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-5048-M207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0481554Medicaid
OH0481554Medicaid
OHA79980Medicare UPIN