Provider Demographics
NPI:1386601391
Name:BIRK, CARL PETER JR (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:PETER
Last Name:BIRK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST
Mailing Address - Street 2:GSBLL
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2730
Mailing Address - Fax:217-876-2735
Practice Address - Street 1:302 W HAY ST
Practice Address - Street 2:STE 140
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4167
Practice Address - Country:US
Practice Address - Phone:217-876-2730
Practice Address - Fax:217-876-2735
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036042482208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042482Medicaid
IL036042482Medicaid
ILK04812Medicare ID - Type Unspecified