Provider Demographics
NPI:1528279031
Name:CARMICHAEL, JASON PATRICK (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:PATRICK
Last Name:CARMICHAEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MONTVALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6924
Mailing Address - Country:US
Mailing Address - Phone:217-726-8096
Mailing Address - Fax:
Practice Address - Street 1:3050 MONTVALE DR STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-726-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0591691207P00000X
MO20170105872085R0202X
IL0361465772085R0202X
IL036.1465772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine