Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YP0228X | Pediatric Otolaryngology | 036-057108 | IL |
NPI | 1356336168 |
---|---|
Provider Name | Carol Gerson |
First Address | River Forest, IL 60305-1435 |
Second Address | River Forest, IL 60305-1435 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/09/2005 |
Last Update Date | 25/04/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036057108 | (05) | IL |
1627123 | BCBS PROVIDER ID (01) | IL |
D15666 | (02) | IL |