Provider Demographics
NPI:1376551671
Name:THOMAS, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:THOMAS
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 1:3050 MONTVALE DR
Mailing Address - Street 2:STE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6924
Mailing Address - Country:US
Mailing Address - Phone:502-583-2731
Mailing Address - Fax:502-583-2733
Practice Address - Street 1:200 ABRAHAM FLEXNER WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1818
Practice Address - Country:US
Practice Address - Phone:502-587-4231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200118122085R0202X
KY348462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200550002Medicaid
KY64003312Medicaid
KY64003312Medicaid