Healthcare Provider Details

I. General information

NPI: 1831454537
Provider Name (Legal Business Name): CAROL P RODGERS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 WILLOW SPRINGS RD SUITE 380
LA GRANGE HIGHLANDS IL
60525-6537
US

IV. Provider business mailing address

5201 WILLOW SPRINGS RD SUITE 380
LA GRANGE HIGHLANDS IL
60525-6537
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-2550
  • Fax: 708-354-4552
Mailing address:
  • Phone: 708-354-2550
  • Fax: 708-354-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209010076
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number041359149
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: