Basic Information
| Provider Information | |||||||||
| NPI: | 1356337133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIGGINS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629181923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189858221 | ||||||||
| FaxNumber: | 6189854635 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S LEWIS LN | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629013547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 03/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036118238 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 133586700 | 01 | IL | FEDERAL WORKERS COMP | OTHER | 370966854002 | 05 | IL | MEDICAID | 036118238 | 05 | IL | MEDICAID | 370966854005 | 05 | IL | MEDICAID | 036118238 | 01 | IL | STATE LICENSE | OTHER | CF3444 | 01 | IL | MEDICARE RAILROAD | OTHER |