Provider Demographics
NPI:1902104037
Name:KIM M CARNAZZOLA MD SC
Entity Type:Organization
Organization Name:KIM M CARNAZZOLA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARNAZZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-996-0607
Mailing Address - Street 1:1860 W WINCHESTER RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5351
Mailing Address - Country:US
Mailing Address - Phone:847-996-0607
Mailing Address - Fax:847-996-0608
Practice Address - Street 1:1860 W WINCHESTER RD
Practice Address - Street 2:SUITE 109
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5351
Practice Address - Country:US
Practice Address - Phone:847-996-0607
Practice Address - Fax:847-996-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G20602Medicare UPIN