Basic Information
| Provider Information | |||||||||
| NPI: | 1982893913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASEBOLT | ||||||||
| FirstName: | KEVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17474 SHAW AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441072217 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 METROHEALTH DR | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441091900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167787800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 02/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 57013475 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2960952 | 05 | OH | MEDICAID |