Basic Information
| Provider Information | |||||||||
| NPI: | 1477599207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 LAFAYETTE AVE SE | ||||||||
| Address2: | FOURTH FLOOR | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164568515 | ||||||||
| FaxNumber: | 6164568208 | ||||||||
| Practice Location | |||||||||
| Address1: | 3565 MOMENTUM PL | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606895335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164568515 | ||||||||
| FaxNumber: | 6164568208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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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 | 207XS0114X | 4301052976 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3382285 | 05 | MI | MEDICAID |