Basic Information
| Provider Information | |||||||||
| NPI: | 1053368498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTHOVEN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4925 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503054925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156434374 | ||||||||
| FaxNumber: | 5156432784 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152473211 | ||||||||
| FaxNumber: | 5156438722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 06/09/2009 | ||||||||
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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 | 207PE0004X | 4301078608 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 06127 | 01 | IA | BC/BS OF IOWA | OTHER | 104703457 | 05 | MI | MEDICAID | KP078608 | 01 | MI | BC/BS OF MICHIGAN | OTHER | 104631572 | 05 | MI | MEDICAID |