Basic Information
| Provider Information | |||||||||
| NPI: | 1598814865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEVIN S WOOLLEY MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1329 LUSITANA STREET | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085311116 | ||||||||
| FaxNumber: | 8085247911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1329 LUSITANA STREET | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085311116 | ||||||||
| FaxNumber: | 8085247911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WOOLLEY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8085311116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD3378 | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 04564901 | 05 | HI | MEDICAID |