Basic Information
| Provider Information | |||||||||
| NPI: | 1851547194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUDZWAARD | ||||||||
| FirstName: | CARMEL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 N. WINFIELD RD. | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | 6309334427 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 N. WINFIELD RD. | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601901295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6309334700 | ||||||||
| FaxNumber: | 6309334427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 036123732 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 036123732 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 036123732 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036123732 | 05 | IL | MEDICAID | 206147 | 01 | IL | MEDICARE PTAN (GROUP) | OTHER | 206147112 | 01 | IL | MEDICARE PTAN (INDIVIDUAL) | OTHER | P01144148 | 01 | IL | RAILROAD MEDICARE INDIVIDUAL PTAN | OTHER |