Provider Demographics
NPI:1174779755
Name:CARLSSON THORN, GUNILLA SIGRID (MD)
Entity type:Individual
Prefix:DR
First Name:GUNILLA
Middle Name:SIGRID
Last Name:CARLSSON THORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FOXFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5799
Mailing Address - Country:US
Mailing Address - Phone:630-315-6500
Mailing Address - Fax:630-615-6519
Practice Address - Street 1:2900 FOXFIELD RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5799
Practice Address - Country:US
Practice Address - Phone:630-315-6500
Practice Address - Fax:630-615-6519
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAN52403945287207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA4748OtherMEDICARE RR (GROUP)
IL036132093Medicaid
IL206147OtherMEDICARE (GROUP)
ILF400094850OtherMEDICARE (INDIVIDUAL)
ILP01324606OtherMEDICARE RR (INDIVIDUAL)