Provider Demographics
NPI:1356337133
Name:HIGGINS, KELLY COLLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:COLLEEN
Last Name:HIGGINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:844-470-2486
Practice Address - Street 1:374 E GRAND AVE # 6740
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3962
Practice Address - Country:US
Practice Address - Phone:618-453-3311
Practice Address - Fax:618-453-4449
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118238207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370966854005Medicaid
ILCF3444OtherMEDICARE RAILROAD
IL036118238OtherSTATE LICENSE
IL133586700OtherFEDERAL WORKERS COMP
IL036118238Medicaid
IL370966854002Medicaid
IL141840Medicare Oscar/Certification
IL036118238OtherSTATE LICENSE