Provider Demographics
NPI:1568183226
Name:CARMICHAEL, CAILEB
Entity Type:Individual
Prefix:
First Name:CAILEB
Middle Name:
Last Name:CARMICHAEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7411 LAKE ST STE 2110
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1886
Mailing Address - Country:US
Mailing Address - Phone:708-848-4662
Mailing Address - Fax:708-613-4319
Practice Address - Street 1:7411 LAKE ST STE 2110
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1886
Practice Address - Country:US
Practice Address - Phone:708-848-4662
Practice Address - Fax:708-613-4319
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-010083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant