Provider Demographics
NPI:1215198189
Name:CARPENTER, KRISTINE ROSS (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ROSS
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:MARIE
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:2512 HURST DR.
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-258-5900
Practice Address - Fax:217-258-3686
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127366207Q00000X
NC149531390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program