Healthcare Provider Details

I. General information

NPI: 1508247602
Provider Name (Legal Business Name): CAROLYN PAYNE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W SUPERIOR ST
CHICAGO IL
60622-5646
US

IV. Provider business mailing address

1701 W SUPERIOR ST
CHICAGO IL
60622-5646
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-3494
  • Fax: 915-533-7158
Mailing address:
  • Phone: 312-666-3494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036154724
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10052876
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS2145
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036154724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: