1962516773 NPI number — CAROLYN A. DICKENS

Table of content: CAROLYN A. DICKENS (NPI 1962516773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962516773 NPI number — CAROLYN A. DICKENS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKENS
Provider First Name:
CAROLYN
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1962516773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 S MARSHFIELD AVE
Provider Second Line Business Mailing Address:
9TH FLOOR (M/C 732)
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60612-4305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-996-7699
Provider Business Mailing Address Fax Number:
312-996-1001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 W TAYLOR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60612-7232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-600-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2006

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: 363L00000X , 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)