Provider Demographics
NPI:1902149123
Name:BLYTHE, KEVIN NATHANIEL (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:NATHANIEL
Last Name:BLYTHE
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:PO BOX 23854
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4489
Mailing Address - Country:US
Mailing Address - Phone:615-647-9005
Mailing Address - Fax:
Practice Address - Street 1:11233 SHADOW CREEK PKWY
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7345
Practice Address - Country:US
Practice Address - Phone:346-324-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56330207P00000X, 207PS0010X
TXS6801207PS0010X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine