=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295952307
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COREY CARR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 12/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13950 W CAPITOL DR 2ND FL
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53005-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-874-6288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 W RIVER WOODS PKWY 3RD FL
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53212-1060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 57243
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------