Provider Demographics
NPI:1972621035
Name:CARL J NOVOTNY DO SC
Entity Type:Organization
Organization Name:CARL J NOVOTNY DO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOVOTNY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-442-7780
Mailing Address - Street 1:8709 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-1128
Mailing Address - Country:US
Mailing Address - Phone:708-442-7780
Mailing Address - Fax:708-442-7797
Practice Address - Street 1:8709 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:NORTH RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-1128
Practice Address - Country:US
Practice Address - Phone:708-442-7780
Practice Address - Fax:708-442-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21621844OtherBLUE SHIELD
IL459660Medicare PIN
IL21621844OtherBLUE SHIELD