Provider Demographics
NPI:1801871017
Name:PHELAN, KAREN (MD)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:WOLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2780 MCFARLAND RD
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6807
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-637-0400
Practice Address - Street 1:2780 MCFARLAND RD
Practice Address - Street 2:PEDIATRICS
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6807
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-637-0400
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070568208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036070568Medicaid
IL036070568OtherSTATE LICENSE
IL480620Medicare ID - Type UnspecifiedMEDICARE PROV ID#
IL036070568Medicaid