Provider Demographics
NPI:1275427395
Name:VAN, KEVIN ANH TAI (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANH TAI
Last Name:VAN
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 1:414 W ROBERT AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-3223
Mailing Address - Country:US
Mailing Address - Phone:303-475-6054
Mailing Address - Fax:
Practice Address - Street 1:16815 E JEFFERSON AVE STE 120
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1923
Practice Address - Country:US
Practice Address - Phone:586-498-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351054412207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine