Provider Demographics
NPI:1295750651
Name:ADDISON, KEVIN C (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:ADDISON
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 1:171 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9500
Mailing Address - Country:US
Mailing Address - Phone:704-660-4390
Mailing Address - Fax:704-660-4399
Practice Address - Street 1:171 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9500
Practice Address - Country:US
Practice Address - Phone:704-660-4390
Practice Address - Fax:704-660-4399
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101272440208M00000X
NC2006-004472080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904803Medicaid
NC2058861Medicare PIN
NCI65219Medicare UPIN