Basic Information
Provider Information | |||||||||
NPI: | 1457353658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARR | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5943 STADIUM DR | ||||||||
Address2: | STE 1 | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490093016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2695522836 | ||||||||
FaxNumber: | 2695522964 | ||||||||
Practice Location | |||||||||
Address1: | 1717 SHAFFER ST | ||||||||
Address2: |   | ||||||||
City: | KALAMAZOO | ||||||||
State: | MI | ||||||||
PostalCode: | 490481647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2692265456 | ||||||||
FaxNumber: | 2692264940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2005 | ||||||||
LastUpdateDate: | 07/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 036106764 | IL | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | 4301067523 | MI | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208G00000X | 4301067523 | MI | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 036106764 | 05 | IL |   | MEDICAID | 286294 | 01 | IL | PERSONAL CARE | OTHER | 370661230 | 01 | IL | TAXPAYER ID # | OTHER | P00320817 | 01 | IL | RR MEDICARE PIN | OTHER | 036106764 | 01 | IL | IL STATE LICENSE | OTHER | 752951 | 01 | IL | HEALTHLINK | OTHER | 1457353658 | 05 | MI |   | MEDICAID | CB3741 | 01 | IL | RR MEDICARE GROUP # | OTHER | 06932023 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |