Basic Information
| Provider Information | |||||||||
| NPI: | 1770831323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALDER | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W TEMPLE AVE | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175402350 | ||||||||
| FaxNumber: | 2173472323 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 W TEMPLE AVE | ||||||||
| Address2: | |||||||||
| City: | EFFINGHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175402350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 2086S0122X | 036-137408 | IL | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036137408 | 05 | IL | MEDICAID |