Provider Demographics
NPI:1275598542
Name:CARNEY, ROBERT GIBSON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:GIBSON
Last Name:CARNEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:SUITE #301
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-429-2636
Mailing Address - Fax:217-429-2687
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:SUITE #301
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-429-2636
Practice Address - Fax:217-429-2687
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2011-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-049753207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071128778OtherRR MEDICARE PROVIDER
IL00882OtherPAYER ID
IL036049753Medicaid
ILD84390Medicare UPIN
IL036049753Medicaid