Basic Information
| Provider Information | |||||||||
| NPI: | 1841272432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606740018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 N WINFIELD RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309338100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 036092734 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 036092734 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036092734 | 05 | IL | MEDICAID |