Provider Demographics
NPI:1801048541
Name:CARLE CLINIC ASSOCIATION, PC
Entity type:Organization
Organization Name:CARLE CLINIC ASSOCIATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:MOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:217-337-4105
Mailing Address - Street 1:1818 E WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-9566
Mailing Address - Country:US
Mailing Address - Phone:217-255-9636
Mailing Address - Fax:
Practice Address - Street 1:1818 E WINDSOR RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-9566
Practice Address - Country:US
Practice Address - Phone:217-255-9636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060009889332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001Medicare NSC
IL754210Medicare PIN
IL991820Medicare PIN
IL396080Medicare PIN
IL407270Medicare PIN
IL279512Medicare PIN