=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790872786
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLE E ROLLINS DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2006
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 LAKE AVE A
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-256-3338
-----------------------------------------------------
Fax | 847-256-4437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1919 LAKE AVE, SUITE A
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-256-4434
-----------------------------------------------------
Fax | 847-256-4437
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 016002846
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------