Basic Information
| Provider Information | |||||||||
| NPI: | 1174611511 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1960 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724031960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709367000 | ||||||||
| FaxNumber: | 8709343677 | ||||||||
| Practice Location | |||||||||
| Address1: | 1109 E REELFOOT AVE STE F | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382615867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318841412 | ||||||||
| FaxNumber: | 7318841720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 8183 | ND | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 27989 | MS | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 57553 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | 111463 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | E-0729 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 10859 | 05 | ND | MEDICAID |