Basic Information
| Provider Information | |||||||||
| NPI: | 1952898215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEGGISON | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | LOGAN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6901 RIVERGATE AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132678082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11375 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525966632 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2018 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | OS18081 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.