Basic Information
| Provider Information | |||||||||
| NPI: | 1538261680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MITCHELL | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 545 PLAINFIELD RD STE C | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605277601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306542229 | ||||||||
| FaxNumber: | 6306553270 | ||||||||
| Practice Location | |||||||||
| Address1: | 545 PLAINFIELD RD STE C | ||||||||
| Address2: | |||||||||
| City: | WILLOWBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605277601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306542229 | ||||||||
| FaxNumber: | 6306553270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036-083442 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 002223846 | 01 | IL | BC/BS | OTHER |