Provider Demographics
NPI:1457353658
Name:CARR, JOHN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:CARR
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 1:5943 STADIUM DR
Mailing Address - Street 2:STE 1
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3016
Mailing Address - Country:US
Mailing Address - Phone:269-552-2836
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:1717 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1647
Practice Address - Country:US
Practice Address - Phone:269-226-5456
Practice Address - Fax:269-226-4940
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106764208600000X
MI4301067523208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106764Medicaid
IL286294OtherPERSONAL CARE
IL370661230OtherTAXPAYER ID #
ILP00320817OtherRR MEDICARE PIN
IL036106764OtherIL STATE LICENSE
IL752951OtherHEALTHLINK
MI1457353658Medicaid
ILCB3741OtherRR MEDICARE GROUP #
IL06932023OtherBLUE CROSS BLUE SHIELD
IL286294OtherPERSONAL CARE
ILP00320817OtherRR MEDICARE PIN
IL213771Medicare ID - Type UnspecifiedMEDICARE GROUP# -LOC 99