Provider Demographics
NPI:1174920128
Name:EMERY, KEVIN JAMES (MT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:EMERY
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MAPLE TREE LN
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110-1455
Mailing Address - Country:US
Mailing Address - Phone:303-229-8113
Mailing Address - Fax:
Practice Address - Street 1:149 MAPLE TREE LN
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110-1455
Practice Address - Country:US
Practice Address - Phone:303-229-8113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0009248174400000X
IL227008088174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist