Healthcare Provider Details

I. General information

NPI: 1629076005
Provider Name (Legal Business Name): WAYNE P CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S RANDALL RD
ALGONQUIN IL
60102-5996
US

IV. Provider business mailing address

PO BOX 1509
ELGIN IL
60121-1509
US

V. Phone/Fax

Practice location:
  • Phone: 224-783-4302
  • Fax: 224-783-4356
Mailing address:
  • Phone: 224-238-4160
  • Fax: 847-783-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036064835
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: