Provider Demographics
NPI:1184659518
Name:HILDRETH, CAROLYN J (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:HILDRETH
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 1:800 W CENTRAL RD
Mailing Address - Street 2:SUITE #137
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2382
Mailing Address - Country:US
Mailing Address - Phone:410-458-9822
Mailing Address - Fax:
Practice Address - Street 1:800 W CENTRAL RD
Practice Address - Street 2:SUITE #137
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-2382
Practice Address - Country:US
Practice Address - Phone:410-458-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.067803207RG0300X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HHH2Medicare ID - Type Unspecified
MD209511400Medicaid
B67108Medicare UPIN