1831199587 NPI number — MS. DAWN CARROLL ROMAN PA-C

Table of content: DR. TEAL KATELYN JENKINS MD (NPI 1205463049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831199587 NPI number — MS. DAWN CARROLL ROMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROMAN
Provider First Name:
DAWN
Provider Middle Name:
CARROLL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GERCHAR
Provider Other First Name:
DAWN
Provider Other Middle Name:
CARROLL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831199587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 SPRINGER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMBARD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60148-6413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-744-8554
Provider Business Mailing Address Fax Number:
630-495-1770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1051 ESSINGTON RD
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-2801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-744-8554
Provider Business Practice Location Address Fax Number:
815-744-3969
Provider Enumeration Date:
07/22/2005

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: 363AS0400X , with the licence number:  10000242A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 085000381 , 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: 01618941 . This is a "BC/BS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com