Basic Information
| Provider Information | |||||||||
| NPI: | 1750382974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | GALE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 88495 | ||||||||
| Address2: | DEPT A | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606801495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307340200 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Practice Location | |||||||||
| Address1: | 3815 HIGHLAND AVE | ||||||||
| Address2: | ADVOCATE GOOD SAMARITAN HOSPITAL | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302755900 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036-100002 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036100002 | 05 | IL | MEDICAID |