Provider Demographics
NPI:1144281080
Name:FITZGERALD, KEVIN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EDWARD
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 1:61 COMMERCE AVE SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4124
Mailing Address - Country:US
Mailing Address - Phone:616-940-0660
Mailing Address - Fax:616-940-1965
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:STE 305
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-285-1377
Practice Address - Fax:616-285-1006
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044533208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4532350-10Medicaid
5648777OtherCIGNA
MI4592438-10Medicaid
23113OtherHEALTH PLAN OF MICHIGAN
MI4507437-10Medicaid
MI550410072OtherBLUE CROSS BLUE SHIELD
P00057547OtherRAILROAD MEDICARE
7000144071OtherPRIORITY HEALTH
4642669OtherAETNA
MI4592438-10Medicaid
MID16000014Medicare PIN