Basic Information
| Provider Information | |||||||||
| NPI: | 1407962012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYD | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 SAINT ANTHONYS WAY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620024569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184622222 | ||||||||
| FaxNumber: | 6184621150 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 SAINT ANTHONYS WAY | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620024569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184622222 | ||||||||
| FaxNumber: | 6184635004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036086462 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036.086462 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036054127 | 05 | IL | MEDICAID | 110191310 | 01 | IL | RAILROAD MEDICARE | OTHER |