Provider Demographics
NPI:1992808489
Name:CARTER, PRENTISS BERNARD III (MD)
Entity type:Individual
Prefix:MR
First Name:PRENTISS
Middle Name:BERNARD
Last Name:CARTER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-5100
Mailing Address - Fax:309-692-1400
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-5100
Practice Address - Fax:309-692-1400
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044919207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL118779OtherHEALTHLINK
IL0007215713OtherBLUE CROSS BLUE SHIELD
IL036044919Medicaid
IL0007215713OtherBLUE CROSS BLUE SHIELD
IL231910Medicare ID - Type Unspecified