Provider Demographics
NPI:1851173330
Name:CAROL STREAM MEDICAL PLLC
Entity type:Organization
Organization Name:CAROL STREAM MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHANELE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-260-0530
Mailing Address - Street 1:270 W ARMY TRAIL ROAD
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-9368
Mailing Address - Country:US
Mailing Address - Phone:630-246-7250
Mailing Address - Fax:630-332-3004
Practice Address - Street 1:270 W ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188
Practice Address - Country:US
Practice Address - Phone:630-517-5674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty