Provider Demographics
NPI:1740212919
Name:BOATWRIGHT, KEVIN DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DALE
Last Name:BOATWRIGHT
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 1:2150 PFINGSTEN RD STE 3000
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1314
Mailing Address - Country:US
Mailing Address - Phone:847-657-5959
Mailing Address - Fax:847-657-5764
Practice Address - Street 1:2150 PFINGSTEN RD STE 3000
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1314
Practice Address - Country:US
Practice Address - Phone:847-657-5959
Practice Address - Fax:847-657-5764
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131723207R00000X, 207RI0200X
NC2006-00619207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC200157944OtherKEY RISK WC
NC2696737OtherUNITED HEALTHCARE
NC5904223Medicaid
NC200157944OtherCOMPCARE
NC200157944OtherSOUTH CARE PPO
NC200157944OtherHEALTHCARE SAVINGS
NC194228OtherMEDCOST
NC200157944OtherEVOLUTIONS
NC142VXOtherBCBS
NC200157944OtherTRICARE FOR LIFE
NC460264OtherWELLPATH
NC7474886OtherAETNA
NC200157944OtherCORVEL WC
NC1508102OtherCIGNA
NCDD2526OtherPALMETTO GBA
NC460264OtherWELLPATH
NC200157944OtherKEY RISK WC
NC808675Medicare ID - Type UnspecifiedPARTNER'S MEDICARE
NC5904223Medicaid
NC2053316BMedicare PIN