Basic Information
| Provider Information | |||||||||
| NPI: | 1558309898 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLILE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4046 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658084046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172691010 | ||||||||
| FaxNumber: | 4172696755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E. PRIMROSE | ||||||||
| Address2: | #200 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172691010 | ||||||||
| FaxNumber: | 4172696755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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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 | 207RC0200X | R8242 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 2080P0203X | 14730 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 196616 | 01 | MO | BLUE SHIELD | OTHER | 701434 | 01 | MO | HEALTHLINK | OTHER | 100199150 A | 05 | OK | MEDICAID | 196616 | 01 | MO | BLUE CHOICE | OTHER | 202969408 | 05 | MO | MEDICAID |