Basic Information
| Provider Information | |||||||||
| NPI: | 1437293537 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARLE CLINIC ASSOCIATION, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833311 | ||||||||
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| Practice Location | |||||||||
| Address1: | 602 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOBERG | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2173374105 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D., PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 060004307 | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 0533210001 | 01 | IL | DMERC | OTHER |