Basic Information
| Provider Information | |||||||||
| NPI: | 1639562358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURFACE | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 S PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489103488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5179753750 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1221 SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897726700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2015 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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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 | 207R00000X | 5101021776 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1639562358 | 05 | MI | MEDICAID |