1558560136 NPI number — ANTHONY B CARTER OD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558560136 NPI number — ANTHONY B CARTER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARTER
Provider First Name:
ANTHONY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

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:
1558560136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4L PLAZA
Provider Second Line Business Mailing Address:
SUITE #35
Provider Business Mailing Address City Name:
GALESBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-343-1179
Provider Business Mailing Address Fax Number:
309-343-5287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4L PLAZA
Provider Second Line Business Practice Location Address:
SUITE #35
Provider Business Practice Location Address City Name:
GALESBURG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-343-1179
Provider Business Practice Location Address Fax Number:
309-343-5287
Provider Enumeration Date:
07/13/2007

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: 152W00000X , with the licence number:  046009984 , 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: 046009984 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04821476 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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