MEDICARE: CAROL LYNN RADOVICH NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	209004029	IL
2	363LA2200X	Adult Health Nurse Practitioner	8119-33	WI

General Provider Information

NPI Number	:	1578511739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL LYNN RADOVICH NP

Provider Business Mailing Address
First Line	:	W197N17054 STONEWALL DR
Second Line	:
City	:	JACKSON
State	:	WI
Zip	:	53037
Country	:	US
Telephone Number	:	847-922-9203
Fax Number	:

Provider Business Practice Location Address
First Line	:	W197N17054 STONEWALL DR
Second Line	:
City	:	JACKSON
State	:	WI
Zip	:	53037
Country	:	US
Telephone Number	:	847-922-9203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	05/01/2019

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