1790872786 NPI number — DR. CARLE E ROLLINS DPM

Table of content: DR. CARLE E ROLLINS DPM (NPI 1790872786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790872786 NPI number — DR. CARLE E ROLLINS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLLINS
Provider First Name:
CARLE
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1790872786
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1919 LAKE AVE, SUITE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMETTE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60091-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-256-4434
Provider Business Mailing Address Fax Number:
847-256-4437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 LAKE AVE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMETTE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60091-1422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-256-3338
Provider Business Practice Location Address Fax Number:
847-256-4437
Provider Enumeration Date:
10/09/2006

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: 213E00000X , with the licence number:  016002846 , 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: 016002846 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60020930 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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