Provider Demographics
NPI:1093978181
Name:POLSLEY, KEVIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:POLSLEY
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 1:15750 MARIAN DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-6200
Mailing Address - Country:US
Mailing Address - Phone:708-645-3400
Mailing Address - Fax:
Practice Address - Street 1:15750 MARIAN DR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6200
Practice Address - Country:US
Practice Address - Phone:708-645-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128061207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine