Basic Information
| Provider Information | |||||||||
| NPI: | 1245415397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKEY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12749 | ||||||||
| Address2: | INDEPENDENT ANESTHESIOLOGISTS PSC | ||||||||
| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410120749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE MEDICAL VILLAGE DRIVE | ||||||||
| Address2: | INDEPENDENT ANESTHESIOLOGISTS PSC | ||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593417246 | ||||||||
| FaxNumber: | 8593417867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2008 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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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 | 163W00000X | 1090399 | KY | N | Nursing Service Providers | Registered Nurse | 163W00000X | 262060 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | 079098 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2833812 | 05 | OH | MEDICAID | 7100032860 | 05 | KY | MEDICAID | 200890500 | 05 | IN | MEDICAID | 9492557 | 01 | PHCS | OTHER | 000000547667 | 01 | ANTHEM | OTHER |