1740212919 NPI number — DR. KEVIN DALE BOATWRIGHT MD

Table of content: (NPI 1912011214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740212919 NPI number — DR. KEVIN DALE BOATWRIGHT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOATWRIGHT
Provider First Name:
KEVIN
Provider Middle Name:
DALE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740212919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2150 PFINGSTEN RD STE 3000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENVIEW
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60026-1314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-657-5959
Provider Business Mailing Address Fax Number:
847-657-5764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 PFINGSTEN RD STE 3000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENVIEW
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60026-1314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-657-5959
Provider Business Practice Location Address Fax Number:
847-657-5764
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  036131723 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 036131723 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200157944 . This is a "KEY RISK WC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2696737 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5904223 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200157944 . This is a "COMPCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 200157944 . This is a "SOUTH CARE PPO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 200157944 . This is a "HEALTHCARE SAVINGS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 194228 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 200157944 . This is a "EVOLUTIONS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 142VX . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 200157944 . This is a "TRICARE FOR LIFE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 460264 . This is a "WELLPATH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7474886 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 200157944 . This is a "CORVEL WC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1508102 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DD2526 . This is a "PALMETTO GBA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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