Basic Information
| Provider Information | |||||||||
| NPI: | 1851369714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KAGAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | JEFFREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8500 LOCK BOX #8302 | ||||||||
| Address2: | SHRINERS HOSPITAL FOR CHILDREN | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191788302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818487 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3229 BURNET AVENUE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138726206 | ||||||||
| FaxNumber: | 5138726396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 03/14/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35-056534 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0122X | 35-056534 | OH | N | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0693692 | 05 | OH | MEDICAID | 64860018 | 05 | KY | MEDICAID |