Basic Information
| Provider Information | |||||||||
| NPI: | 1093797045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMULLEN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123765315 | ||||||||
| FaxNumber: | 8123753477 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 17TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123765550 | ||||||||
| FaxNumber: | 8123765930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 9900941 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 01070320A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 201037980 | 05 | IN | MEDICAID | 802872 | 01 | NC | PARTNERS | OTHER | 2004948000 | 05 | WV | MEDICAID | 1333U | 01 | NC | BCBS | OTHER | 891333U | 05 | NC | MEDICAID | Q0094C | 05 | SC | MEDICAID | C6010 | 01 | NC | MEDCOST | OTHER | 10001251 | 05 | VA | MEDICAID | 000000746372 | 01 | IN | ANTHEM | OTHER | 000000990588 | 01 | IN | ANTHEM PIN | OTHER | P01420734 | 01 | IN | RAILROAD MEDICARE | OTHER | 7957688 | 01 | AETNA | OTHER |