Provider Demographics
NPI:1659555464
Name:KEVIN C DODSON
Entity Type:Organization
Organization Name:KEVIN C DODSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-755-3809
Mailing Address - Street 1:1620 9TH ST
Mailing Address - Street 2:P O BOX 664
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-2120
Mailing Address - Country:US
Mailing Address - Phone:309-755-3809
Mailing Address - Fax:308-755-3860
Practice Address - Street 1:1620 9TH ST
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-2120
Practice Address - Country:US
Practice Address - Phone:309-755-3809
Practice Address - Fax:308-755-3860
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEVIN C DODSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-28
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004304332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060201286OtherBLUE CROSS BLUE SHIELD
ILIL0101OtherUNITED HEALTHCARE
IA0436154OtherIME
IAP00204462OtherMEDICARE RAILROAD
IL480007485OtherMEDICARE RAILROAD
IAIA0102OtherUNITED HEALTH CARE
IL020110OtherHEALTH ALLIANCE
IL326507258OtherTRICARE
IA36473OtherWELLMARK BLUE CROSS/BLUE SHIELD
IAI12453OtherMEDICARE
IL326507258OtherTRICARE
IAP00204462OtherMEDICARE RAILROAD
IA36473OtherWELLMARK BLUE CROSS/BLUE SHIELD