Healthcare Provider Details

I. General information

NPI: 1255519310
Provider Name (Legal Business Name): CAROL KROHM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 W CHICAGO AVE
CHICAGO IL
60622
US

IV. Provider business mailing address

BOX 430 20605 E BRINK ST
HARVARD IL
60033-0430
US

V. Phone/Fax

Practice location:
  • Phone: 773-395-9901
  • Fax: 773-395-9902
Mailing address:
  • Phone: 815-943-6905
  • Fax: 708-401-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2825020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: