Provider Demographics
NPI:1972528255
Name:KIRBY, KEVIN J (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KIRBY
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 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:1701 W CURTIS ROAD
Practice Address - Street 2:FAMILY MEDICINE/CONVENIENT CARE
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-365-6201
Practice Address - Fax:217-326-1234
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6447860004Medicare NSC
ILC43387Medicare UPIN
IL0533210001Medicare NSC
C43387Medicare UPIN
ILIL3270372Medicare PIN