Provider Demographics
NPI:1235372996
Name:ROBB-RAREY, CANDICE ROSE
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:ROSE
Last Name:ROBB-RAREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-653-0848
Mailing Address - Fax:630-933-3710
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-653-0848
Practice Address - Fax:630-933-3710
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128471207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDB1658OtherRR MEDICARE PTAN (GROUP)
IL036128471Medicaid
IL920540OtherMEDICARE PTAN (GROUP)
IL920540029OtherMEDICARE PTAN (INDIVIDUAL)
ILP01098968OtherRR MEDICARE PTAN (INDIVIDUAL)