Provider Demographics
NPI:1477549020
Name:OLIVER, KEVIN M (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:OLIVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 STEVENS CREEK BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:IL
Mailing Address - Zip Code:62535-9741
Mailing Address - Country:US
Mailing Address - Phone:217-875-0717
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J38207P00000X, 207Q00000X
IL036-116436207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116436Medicaid
MO243001013Medicaid
ILK41132Medicare PIN
ILK40082Medicare PIN
ILK41131Medicare PIN
ILK31281Medicare PIN