Basic Information
| Provider Information | |||||||||
| NPI: | 1932396942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEVIN T OCONNOR DO PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 326 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488110326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895846801 | ||||||||
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| Practice Location | |||||||||
| Address1: | 421 S BALDWIN ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488382102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895846801 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | OCONNOR | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9895846801 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 5101010639 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3526975 | 05 | MI | MEDICAID | 0255900344 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |