1801871017 NPI number — DR. KAREN PHELAN MD

Table of content: DR. KAREN PHELAN MD (NPI 1801871017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801871017 NPI number — DR. KAREN PHELAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHELAN
Provider First Name:
KAREN
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:
WOLL
Provider Other First Name:
KAREN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801871017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2780 MCFARLAND RD
Provider Second Line Business Mailing Address:
PEDIATRICS
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-6807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-971-2000
Provider Business Mailing Address Fax Number:
815-637-0400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2780 MCFARLAND RD
Provider Second Line Business Practice Location Address:
PEDIATRICS
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-6807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-971-2000
Provider Business Practice Location Address Fax Number:
815-637-0400
Provider Enumeration Date:
12/09/2005

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: 208000000X , with the licence number:  036070568 , 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: 036070568 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036070568 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".