Individual
ELAINE MARIE CARROLL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1508 W REYNOLDS ST, PONTIAC, IL 61764-2811
(815) 844-4611
Mailing address
611 W PARK ST, URBANA, IL 61801-2529
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
36085505
IL
207VM0101X
Maternal & Fetal Medicine Physician
01076901A
IN
207VM0101X
Maternal & Fetal Medicine Physician
036085505
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036085505
—
IL
01
—
181980007
MEDICARE PTAN
IN
05
—
200265610
—
IN
01
—
206147
MEDICARE PTAN (GROUP)
IL
01
—
206147098
MEDICARE PTAN (INDIVIDUAL)
IL
Enumeration date
02/15/2006
Last updated
04/20/2022
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