Active NPI
Wayne P Carlson, MD
- Family Medicine Physician
- Algonquin, IL
National Provider Identifier
1629076005
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 036064835
- Practice address
- 600 S Randall Rd
Algonquin, IL 60102-5996 - Phone
- (224) 783-4302
- Fax
- (224) 783-4356
- NPI assigned
- Jul 11, 2005
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 036064835 | IL | Primary |
Addresses
Primary practice location
600 S Randall Rd
Algonquin, IL 60102-5996
Mailing address
PO Box 1509
Elgin, IL 60121-1509
Phone (224) 238-4160
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036064835 | Medicaid | IL | |
| 05632414 | Other | IL | BCBS PROV # |
| 612038400 | Other | IL | IL DEPT OF LABOR |
| 05623112 | Other | IL | BLUE CROSS BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1121040000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1307923200000",
"number": "1629076005",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1509",
"city": "ELGIN",
"state": "IL",
"postal_code": "601211509",
"telephone_number": "224-238-4160",
"fax_number": "847-783-0599"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "600 S RANDALL RD",
"city": "ALGONQUIN",
"state": "IL",
"postal_code": "601025996",
"telephone_number": "224-783-4302",
"fax_number": "224-783-4356"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CARLSON",
"first_name": "WAYNE",
"middle_name": "P",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-07-11",
"last_updated": "2011-06-13",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IL",
"license": "036064835",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036064835",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS PROV #",
"identifier": "05632414",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "IL DEPT OF LABOR",
"identifier": "612038400",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "05623112",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Algonquin, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.