Provider Demographics
NPI:1922159037
Name:GARNER, KEVIN BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BRADLEY
Last Name:GARNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6812 STATE ROUTE 162
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8553
Mailing Address - Country:US
Mailing Address - Phone:618-288-2120
Mailing Address - Fax:618-288-2123
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:SUITE 204
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8553
Practice Address - Country:US
Practice Address - Phone:618-288-2120
Practice Address - Fax:618-288-2123
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074997Medicaid
ILL17982Medicare ID - Type Unspecified
IL036074997Medicaid