Basic Information
| Provider Information | |||||||||
| NPI: | 1679837520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARTHUR | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 SALUDA POINTE DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290727295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967846 | ||||||||
| FaxNumber: | 8032969699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 2016025179 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207QS0010X | 81754 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200034069 | 05 | MO | MEDICAID | 817548 | 05 | SC | MEDICAID | 1679837520 | 05 | MO | MEDICAID |