1295725323 NPI number — DR. CARRIE SHARKEY MD

Table of content: DR. CARRIE SHARKEY MD (NPI 1295725323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295725323 NPI number — DR. CARRIE SHARKEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHARKEY
Provider First Name:
CARRIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHARKEY-ASNER
Provider Other First Name:
CARRIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295725323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 PARKVIEW AVENUE
Provider Second Line Business Mailing Address:
CREDENTIALING S200C
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-2231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-395-5861
Provider Business Mailing Address Fax Number:
815-395-5575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 E STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61104-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-972-1000
Provider Business Practice Location Address Fax Number:
815-972-1086
Provider Enumeration Date:
10/28/2005

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: 207Q00000X , with the licence number:  036082688 , 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: 036082688 . This is a "IL STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036082688 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 336044959 . This is a "IL STATE CTL SUBS LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".