Provider Demographics
NPI:1174522197
Name:PRITCHETT, KEVIN L (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:PRITCHETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00349295OtherMEDICARE RAILROAD
IL036072222Medicaid
IL036072222Medicaid
ILC48939Medicare UPIN