Basic Information
| Provider Information | |||||||||
| NPI: | 1033201033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUSK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1028 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475471028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129960410 | ||||||||
| FaxNumber: | 8129968497 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FERDINAND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475329534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123671906 | ||||||||
| FaxNumber: | 8123672487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01048988A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200441670B | 05 | IN | MEDICAID |