1609087121 NPI number — BRYAN CARROLL M.D.

Table of content: BRYAN CARROLL M.D. (NPI 1609087121)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609087121 NPI number — BRYAN CARROLL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
BRYAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609087121
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11100 EUCLID AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44106-1716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-844-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 CLAGUE RD BLDG B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTLAKE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44145-1533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-844-8200
Provider Business Practice Location Address Fax Number:
440-250-2022
Provider Enumeration Date:
05/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  0101252291 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: 35.137019 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10097097 . This is a "OPTIMA HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609087121 . This is a "COVENTRY HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 5921028 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1609087121 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "MULTIPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: -005 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 473606 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "CORVEL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609087121 . This is a "VIRGINIA PREMIER HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609087121 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAR . This is a "USA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: PAR . This is a "VIRGINIA HEALTH NETWORK" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".