Basic Information
| Provider Information | |||||||||
| NPI: | 1689654360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 745462 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303745462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407862100 | ||||||||
| FaxNumber: | 5407860677 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224018424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407857810 | ||||||||
| FaxNumber: | 5407863099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 05/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101237887 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0101237887 | 01 | VA | LICENSE | OTHER | 8133869 | 01 | VA | MAMSI | OTHER | 000593674 | 01 | VA | AETNA CAP | OTHER | 178521 | 01 | VA | ANTHEM | OTHER | 3780363 | 01 | VA | AETNA HMO | OTHER | CA9037 | 01 | VA | MCR RAILROAD GROUP | OTHER | 7417660 | 01 | VA | AETNA NON HMO | OTHER | 010163323 | 05 | VA | MEDICAID | CO2375 | 01 | VA | MEDICARE GROUP | OTHER |