Provider Demographics
NPI:1831454537
Name:RODGERS, CAROL P (NP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:P
Last Name:RODGERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:LA GRANGE HIGHLANDS
Mailing Address - State:IL
Mailing Address - Zip Code:60525-6537
Mailing Address - Country:US
Mailing Address - Phone:708-354-2550
Mailing Address - Fax:708-354-4552
Practice Address - Street 1:5201 WILLOW SPRINGS RD
Practice Address - Street 2:SUITE 380
Practice Address - City:LA GRANGE HIGHLANDS
Practice Address - State:IL
Practice Address - Zip Code:60525-6537
Practice Address - Country:US
Practice Address - Phone:708-354-2550
Practice Address - Fax:708-354-4552
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041359149163WU0100X
IL209010076363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WU0100XNursing Service ProvidersRegistered NurseUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
214706037Medicare PIN
212549003Medicare PIN