Provider Demographics
NPI:1063490183
Name:HENRY, KEVIN M (MD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:M
Last Name:HENRY
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 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 416
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-7246
Mailing Address - Fax:309-692-7226
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 416
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-7246
Practice Address - Fax:309-692-7226
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10492207LP2900X
IL036114669207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114669Medicaid
ILK28518Medicare PIN
IL036114669Medicaid