Provider Demographics
NPI:1871541615
Name:JEFFRIES, KEVIN M (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:JEFFRIES
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 1:336 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:GALVA
Mailing Address - State:IL
Mailing Address - Zip Code:61434-1365
Mailing Address - Country:US
Mailing Address - Phone:309-932-3101
Mailing Address - Fax:309-932-3154
Practice Address - Street 1:336 FRONT ST
Practice Address - Street 2:
Practice Address - City:GALVA
Practice Address - State:IL
Practice Address - Zip Code:61434-1365
Practice Address - Country:US
Practice Address - Phone:309-932-3101
Practice Address - Fax:309-932-3154
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090015Medicaid
ILF68855Medicare UPIN
IL036090015Medicaid