Provider Demographics
NPI:1891113775
Name:CARROLL, BRIAN JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOHN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 PARK AVE W STE 2800
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2557
Mailing Address - Country:US
Mailing Address - Phone:847-432-1558
Mailing Address - Fax:847-432-6981
Practice Address - Street 1:757 PARK AVE W STE 2800
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035
Practice Address - Country:US
Practice Address - Phone:847-752-4497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125064529207V00000X
IL336.107615207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty