Provider Demographics
NPI:1629076005
Name:CARLSON, WAYNE P (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:P
Last Name:CARLSON
Suffix:
Gender:M
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:PO BOX 1509
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60121-1509
Mailing Address - Country:US
Mailing Address - Phone:224-238-4160
Mailing Address - Fax:847-783-0599
Practice Address - Street 1:600 S RANDALL RD
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5996
Practice Address - Country:US
Practice Address - Phone:224-783-4302
Practice Address - Fax:224-783-4356
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064835207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064835Medicaid
IL05632414OtherBCBS PROV #
IL612038400OtherIL DEPT OF LABOR
IL05623112OtherBLUE CROSS BLUE SHIELD
IL209303Medicare PIN
ILP00432055Medicare PIN
ILC43364Medicare UPIN
IL036064835Medicaid
IL05632414OtherBCBS PROV #
ILIL2305004Medicare PIN