Provider Demographics
NPI:1154331411
Name:MALONE, KEVIN D (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:D
Last Name:MALONE
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1104 W EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1710
Practice Address - Country:US
Practice Address - Phone:217-347-2500
Practice Address - Fax:217-342-9775
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092819208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092819Medicaid
IL036092819Medicaid
ILL93155Medicare ID - Type UnspecifiedMEDICARE