Basic Information
| Provider Information | |||||||||
| NPI: | 1053364349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGUERO-MEDINA | ||||||||
| FirstName: | CARLOS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 N RACINE AVE | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606071644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3127339730 | ||||||||
| FaxNumber: | 7738668014 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611041012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156687810 | ||||||||
| FaxNumber: | 8157146219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 54638-20 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036115945 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | AGUERCAR | 01 | WI | MERCYCARE INSURANCE | OTHER | 036115945 | 01 | IL | STATE LICENSE | OTHER |