Basic Information
Provider Information | |||||||||
NPI: | 1366542599 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TREMBUSH | ||||||||
FirstName: | KEVIN | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.C. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 699 BURROUGHS ST | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265053361 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042259355 | ||||||||
FaxNumber: | 3042259358 | ||||||||
Practice Location | |||||||||
Address1: | 699 BURROUGHS ST | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265053361 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042259355 | ||||||||
FaxNumber: | 3042259358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2006 | ||||||||
LastUpdateDate: | 07/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 0769 | WV | Y |   | Chiropractic Providers | Chiropractor |   |
ID Information
ID | Type | State | Issuer | Description | 001708517 | 01 | WV | BLUE CROSS BLUE SHEILD | OTHER | 1083943484 | 01 | WV | CIGNA GOVERNMENT SERVICES | OTHER | 271821 | 01 | WV | CARELINK | OTHER | 5642046 | 01 | WV | FIRST HEALTH | OTHER | 364502237 | 01 | WV | EMPLOYER IDENTIFICATION # | OTHER | P00337891 | 01 | WV | RAIL ROAD MEDICARE | OTHER | 3810003265 | 05 | WV |   | MEDICAID | 11451727 | 01 | WV | CAQH | OTHER | 7254278 | 01 | WV | AETNA | OTHER |