Provider Demographics
NPI:1093978181
Name:POLSLEY, KEVIN R (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:R
Last Name:POLSLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7425 JANES AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2357
Mailing Address - Country:US
Mailing Address - Phone:331-732-7100
Mailing Address - Fax:331-732-7101
Practice Address - Street 1:7425 JANES AVE STE 100
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2357
Practice Address - Country:US
Practice Address - Phone:331-732-7100
Practice Address - Fax:331-732-7101
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.128061208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine