Basic Information
| Provider Information | |||||||||
| NPI: | 1164643789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | KYLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 859 | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855470859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284724675 | ||||||||
| FaxNumber: | 9284723431 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 E MAIN ST STE B | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855415488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284724675 | ||||||||
| FaxNumber: | 9284723431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 10/05/2011 | ||||||||
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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 | 04-32629 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 44721 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110150004 | 01 | KS | MEDICARE | OTHER | 623101 | 05 | AZ | MEDICAID | 200573240A | 05 | KS | MEDICAID | 110171004 | 01 | KS | MEDICARE | OTHER |