Provider Demographics
NPI:1407967714
Name:CORBRIDGE, CAROL L (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:CORBRIDGE
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 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 155
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-563-3269
Mailing Address - Fax:312-563-3272
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 155
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-563-3269
Practice Address - Fax:312-563-3272
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0711982085R0202X
MI43010887812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4931452Medicaid
ILL88098Medicare ID - Type Unspecified
MI4931452Medicaid