Provider Demographics
NPI:1235284357
Name:ROYER, CAROL ANN (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:ROYER
Suffix:
Gender:F
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:PO BOX 8016
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-8016
Mailing Address - Country:US
Mailing Address - Phone:574-271-7911
Mailing Address - Fax:
Practice Address - Street 1:611 E. DOUGLAS RD.
Practice Address - Street 2:SUITE 128
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6210
Practice Address - Fax:574-335-6211
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030119207Q00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100091090BMedicaid
IN164400Medicare ID - Type UnspecifiedMEDCIARE PROVIDER NUMBER