Healthcare Provider Details

I. General information

NPI: 1568183226
Provider Name (Legal Business Name): CAILEB CARMICHAEL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 N CALIFORNIA AVE STE F804
CHICAGO IL
60625-7014
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 773-907-7750
  • Fax: 773-907-7760
Mailing address:
  • Phone: 847-982-3175
  • Fax: 847-335-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085010083
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: