Provider Demographics
NPI:1205872462
Name:FITZPATRICK, CAROLYN ELAINE (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELAINE
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ELAINE
Other - Last Name:JOYNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 ERIE CT
Mailing Address - Street 2:SUITE 6160
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2566
Mailing Address - Country:US
Mailing Address - Phone:708-763-1490
Mailing Address - Fax:708-763-7232
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:SUITE 6160
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:708-763-1490
Practice Address - Fax:708-763-7232
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI44965Medicare UPIN
ILK22363Medicare ID - Type Unspecified