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General NPI Number Information
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NPI Number | 1609906999
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Entity Type | Organization
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Legal Business Name | CARLE CLINIC ASSOCIATION
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Dates
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Enumeration Date | 03/06/2007
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Last Update Date | 08/31/2009
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Provider Practice Location Address
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Address Line | 701 KREBS DR
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City | CHAMPAIGN
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State | IL
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Zip | 61822
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Country | US
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Telephone | 217-355-7951
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Fax |
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Provider Business Mailing Address
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Address Line | 701 KREBS DR
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City | CHAMPAIGN
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State | IL
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Zip | 61822
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | HOSPITALIST
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Name | ZUHEIR KASSABO
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Credential | MD
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Telephone | 217-355-7951
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 036-115508
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | 036-115508
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License Number State | IL
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Legacy Identifiers
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Identifier #1
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Identifier Code | 036115508
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Identifier Type | MEDICAID
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Identifier State | IL
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Identifier Issuer |
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Identifier #2
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Identifier Code | CA2264
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Identifier Type | OTHER
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Identifier State | IL
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Identifier Issuer | RR GROUP #
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Identifier #3
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Identifier Code | 833120
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Identifier Type | OTHER
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Identifier State |
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Identifier Issuer | MEDICARE GROUP #
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Identifier #4
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Identifier Code | P00729199
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Identifier Type | OTHER
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Identifier State | IL
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Identifier Issuer | RR MEDICARE INDIVIDUAL #
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 036115508
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Identifier Type | MEDICAID
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Identifier State | IL
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Identifier Issuer |
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Identifier #2
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Identifier Code | 833120
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Identifier Type | OTHER
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Identifier State |
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Identifier Issuer | MEDICARE GROUP #
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Identifier #3
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Identifier Code | CA2264
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Identifier Type | OTHER
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Identifier State | IL
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Identifier Issuer | RR GROUP #
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Identifier #4
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Identifier Code | P00729199
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Identifier Type | OTHER
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Identifier State | IL
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Identifier Issuer | RR MEDICARE INDIVIDUAL #
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