Provider Demographics
NPI:1386726255
Name:CARLSON, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SAINT CLARE CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9239
Mailing Address - Country:US
Mailing Address - Phone:309-886-4003
Mailing Address - Fax:309-886-4116
Practice Address - Street 1:10 SAINT CLARE CT
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9239
Practice Address - Country:US
Practice Address - Phone:309-886-4003
Practice Address - Fax:309-886-4116
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-076809208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076809Medicaid
ILK18888Medicare ID - Type UnspecifiedINDIVIDUAL #
IL809840Medicare ID - Type UnspecifiedGROUP #
H08889Medicare UPIN
IL036076809Medicaid