Basic Information
| Provider Information | |||||||||
| NPI: | 1285675892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARVIN | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ARVIN | ||||||||
| OtherFirstName: | JON | ||||||||
| OtherMiddleName: | ANTHONY | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1010 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | MC KEE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404477089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596267700 | ||||||||
| FaxNumber: | 8596267890 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 PROGRESS DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404568590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062562143 | ||||||||
| FaxNumber: | 6062569762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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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 | 33743 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65905895 | 05 | KY | MEDICAID | 64337439 | 05 | KY | MEDICAID |