Provider Demographics
NPI:1063464337
Name:MCCARTHY, CAROLYN T (NP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:T
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:003-262-2508
Mailing Address - Fax:
Practice Address - Street 1:130 W BRUCE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1667
Practice Address - Country:US
Practice Address - Phone:414-384-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704216109363L00000X
WI13525-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014626Medicaid
MI4850425Medicaid
MI4850407Medicaid
MI4850416Medicaid
MI700D114790OtherBCBS GROUP #
MI4850407Medicaid
MI4850416Medicaid
MI4850381Medicaid