Healthcare Provider Details

I. General information

NPI: 1417974957
Provider Name (Legal Business Name): CAROL HURLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEMORIAL DR
ALTON IL
62002-6722
US

IV. Provider business mailing address

75 REMIT DRIVE LOCKBOX 1876
CHICAGO IL
60675-1876
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-0600
  • Fax:
Mailing address:
  • Phone: 866-916-5259
  • Fax: 231-922-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-041772
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30276
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR4135
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: