Provider Demographics
NPI:1144754607
Name:PHAM, KEVIN K (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-1863
Mailing Address - Country:US
Mailing Address - Phone:618-257-6220
Mailing Address - Fax:618-257-6679
Practice Address - Street 1:414 S STATE ST
Practice Address - Street 2:
Practice Address - City:ROODHOUSE
Practice Address - State:IL
Practice Address - Zip Code:62082
Practice Address - Country:US
Practice Address - Phone:217-589-4383
Practice Address - Fax:217-589-4409
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036157104207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-6013958OtherIRS