Provider Demographics
NPI:1730219627
Name:CARLE CLINIC ASSOCIATION, PC
Entity type:Organization
Organization Name:CARLE CLINIC ASSOCIATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-383-3311
Mailing Address - Street 1:4000 GREEN APPLE LANE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1175
Mailing Address - Country:US
Mailing Address - Phone:217-762-2518
Mailing Address - Fax:
Practice Address - Street 1:4000 GREEN APPLE LANE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1175
Practice Address - Country:US
Practice Address - Phone:217-762-2518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009052332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL754210Medicare ID - Type Unspecified
IL0533210001Medicare NSC