Provider Demographics
NPI:1871535450
Name:SHIVELY, KARLA R (DO)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:R
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:330 MADISON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6565
Mailing Address - Country:US
Mailing Address - Phone:815-725-3440
Mailing Address - Fax:815-725-7209
Practice Address - Street 1:330 MADISON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6565
Practice Address - Country:US
Practice Address - Phone:815-725-3440
Practice Address - Fax:815-725-7209
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2010-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036091518207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091518Medicaid
IL1932141579Medicare NSC
G19974Medicare UPIN
ILL69643Medicare PIN