Provider Demographics
NPI:1710092655
Name:EGLY, KEVIN D (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:D
Last Name:EGLY
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 1:203 WILLOWWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7505
Mailing Address - Country:US
Mailing Address - Phone:630-554-0074
Mailing Address - Fax:
Practice Address - Street 1:11 E PLEASANT AVE
Practice Address - Street 2:ROOM 129
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1100
Practice Address - Country:US
Practice Address - Phone:815-786-6988
Practice Address - Fax:815-786-1418
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101052208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101052Medicaid
ILK10069Medicare ID - Type Unspecified
IL036101052Medicaid