Provider Demographics
NPI:1417974957
Name:HURLEY, CAROL (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:HURLEY
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 1:75 REMIT DRIVE
Mailing Address - Street 2:LOCKBOX 1876
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1876
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:314-434-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-041772207P00000X
KY30276207P00000X
MOR4135207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208240515Medicaid
IL036041772Medicaid
MO1417974957Medicaid
ILIL16872048Medicare PIN
ILK31612Medicare PIN
F65437Medicare UPIN
MO1417974957Medicaid