Basic Information
| Provider Information | |||||||||
| NPI: | 1164421509 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORDEAU | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 BOWER HILL ROAD | ||||||||
| Address2: | ATTN PAMALYN AFFILIATE BILLING | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152431873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129422548 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1145 BOWER HILL RD | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152431342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4125726194 | ||||||||
| FaxNumber: | 4125726195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD425640 | PA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | P00230561 | 01 | PA | PALMETTO | OTHER | 1545957 | 01 | PA | GATEWAY | OTHER |