Provider Demographics
NPI:1902999683
Name:KEVIN L PRITCHETT M.D PC
Entity Type:Organization
Organization Name:KEVIN L PRITCHETT M.D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PRITCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-632-3565
Mailing Address - Street 1:100 SPRINGFIELD CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2495
Mailing Address - Country:US
Mailing Address - Phone:618-632-3565
Mailing Address - Fax:618-632-7693
Practice Address - Street 1:100 SPRINGFIELD CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2495
Practice Address - Country:US
Practice Address - Phone:618-632-3565
Practice Address - Fax:618-632-7693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00349295OtherMEDICARE RAILROAD
IL214065OtherMEDICARE GROUP NUMBER
ILC48939Medicare UPIN
IL214065OtherMEDICARE GROUP NUMBER