Provider Demographics
NPI:1386759710
Name:CORCORAN, MARIE ELLEN (D/O)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ELLEN
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:D/O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BLANCHARD CIR
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-2039
Mailing Address - Country:US
Mailing Address - Phone:630-510-9009
Mailing Address - Fax:630-510-0152
Practice Address - Street 1:7 BLANCHARD CIR
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-2039
Practice Address - Country:US
Practice Address - Phone:630-510-9009
Practice Address - Fax:630-510-0152
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058883207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0222075OtherBLUE CROSS GROUP NUMBER
010044842OtherR/R MEDICARE
IL036058883Medicaid
IL3631498336019001OtherCDPG HFS PAYEE ID
IL363149833OtherTAX IDENTIFICATION NUMBER
IL363149833OtherTAX IDENTIFICATION NUMBER
IL427562Medicare ID - Type Unspecified