Healthcare Provider Details

I. General information

NPI: 1336214782
Provider Name (Legal Business Name): KELLY MARIE CARUSO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 12/23/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20060 GOVERNORS DR STE 300
OLYMPIA FIELDS IL
60461-1099
US

IV. Provider business mailing address

20060 GOVERNORS DR STE 300
OLYMPIA FIELDS IL
60461-1099
US

V. Phone/Fax

Practice location:
  • Phone: 708-283-2600
  • Fax: 708-833-7248
Mailing address:
  • Phone: 708-283-2600
  • Fax: 708-833-7248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002871
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: