Provider Demographics
NPI:1578559811
Name:FITZGERALD, KEVIN R (MD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:R
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 AUBURN AVENUE
Mailing Address - Street 2:SUITE 724
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219
Mailing Address - Country:US
Mailing Address - Phone:513-241-4774
Mailing Address - Fax:513-241-1682
Practice Address - Street 1:2123 AUBURN AVENUE
Practice Address - Street 2:SUITE 724
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219
Practice Address - Country:US
Practice Address - Phone:513-241-4774
Practice Address - Fax:513-241-1682
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055457F207V00000X
IN01032783A207V00000X
VT0420008213207V00000X
OH35-055457-F207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0669638Medicaid
FI0601512Medicare PIN
OHA17009Medicare UPIN
OH0669638Medicaid