Healthcare Provider Details

I. General information

NPI: 1114931375
Provider Name (Legal Business Name): META CARROLL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WINFIELD RD
WINFIELD IL
60190-1379
US

IV. Provider business mailing address

225 E CHICAGO AVE # 62
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-1602
  • Fax:
Mailing address:
  • Phone: 312-227-6080
  • Fax: 312-227-9475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD26082
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberMD00045233
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: