Provider Demographics
NPI:1356336168
Name:GERSON, CAROL (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:GERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1435
Mailing Address - Country:US
Mailing Address - Phone:708-334-5160
Mailing Address - Fax:
Practice Address - Street 1:1031 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1435
Practice Address - Country:US
Practice Address - Phone:708-334-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057108207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1627123OtherBCBS PROVIDER ID
IL036057108Medicaid
IL1627123OtherBCBS PROVIDER ID
IL036057108Medicaid