Basic Information
| Provider Information | |||||||||
| NPI: | 1205999851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHERLOCK | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 N WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474043525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123348958 | ||||||||
| FaxNumber: | 8123348881 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 17TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123348958 | ||||||||
| FaxNumber: | 8123348881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01049800A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200480020A | 05 | IN | MEDICAID |