Basic Information
| Provider Information | |||||||||
| NPI: | 1629076005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1509 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601211509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2242384160 | ||||||||
| FaxNumber: | 8477830599 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 S RANDALL RD | ||||||||
| Address2: | |||||||||
| City: | ALGONQUIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601025996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2247834302 | ||||||||
| FaxNumber: | 2247834356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 06/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036064835 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036064835 | 05 | IL | MEDICAID | 05632414 | 01 | IL | BCBS PROV # | OTHER | 612038400 | 01 | IL | IL DEPT OF LABOR | OTHER | 05623112 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |