1750375572 NPI number — MRS. CARRIE E GOLDEN-BRENNER M.D.

Table of content: MRS. CARRIE E GOLDEN-BRENNER M.D. (NPI 1750375572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750375572 NPI number — MRS. CARRIE E GOLDEN-BRENNER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLDEN-BRENNER
Provider First Name:
CARRIE
Provider Middle Name:
E
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLDEN
Provider Other First Name:
CARRIE
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750375572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 AUSTIN
Provider Second Line Business Mailing Address:
SUITE 151
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-328-2300
Provider Business Mailing Address Fax Number:
847-492-1988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 AUSTIN
Provider Second Line Business Practice Location Address:
SUITE 151
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-328-2300
Provider Business Practice Location Address Fax Number:
847-492-1988
Provider Enumeration Date:
09/08/2005

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: 207W00000X , with the licence number:  36-69488 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 036.069488 , 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: 036069488 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01623637 . This is a "BCBS NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 01623637 . This is a "BLUE SHIELD NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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