Healthcare Provider Details

I. General information

NPI: 1902999683
Provider Name (Legal Business Name): KEVIN L PRITCHETT M.D PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SPRINGFIELD CT
O FALLON IL
62269-2495
US

IV. Provider business mailing address

100 SPRINGFIELD CT
O FALLON IL
62269-2495
US

V. Phone/Fax

Practice location:
  • Phone: 618-632-3565
  • Fax: 618-632-7693
Mailing address:
  • Phone: 618-632-3565
  • Fax: 618-632-7693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036072222
License Number StateIL

VIII. Authorized Official

Name: DR. KEVIN L PRITCHETT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 618-632-3565