Provider Demographics
NPI:1184136962
Name:EUGENE KEVIN O'HEA
Entity type:Organization
Organization Name:EUGENE KEVIN O'HEA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:O'HEA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-947-3377
Mailing Address - Street 1:697 MANILA ST
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-6505
Mailing Address - Country:US
Mailing Address - Phone:601-947-3377
Mailing Address - Fax:601-947-3380
Practice Address - Street 1:697 MANILA ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6505
Practice Address - Country:US
Practice Address - Phone:601-947-3377
Practice Address - Fax:601-947-3380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-01
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117316Medicaid