Provider Demographics
NPI:1902245194
Name:KEVERN, ERIN MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIN
Middle Name:MARIE
Last Name:KEVERN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:1753 FULTON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1927
Practice Address - Country:US
Practice Address - Phone:574-293-9448
Practice Address - Fax:574-293-9480
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020418207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300014225Medicaid