Provider Demographics
NPI:1053395269
Name:KERVIN, CHARLES DANIEL (AA-C)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DANIEL
Last Name:KERVIN
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 JESSE HILL JR DR SE
Mailing Address - Street 2:ANESTHESIA DEPT.
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3031
Mailing Address - Country:US
Mailing Address - Phone:404-616-5519
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-616-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2342367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA0005Medicaid
SCGP2991Medicaid
S34069Medicare UPIN
SCAA0005Medicaid
SC6877Medicare ID - Type UnspecifiedGROUP