1730420811 NPI number — CARROLL MEDICAL GROUP

Table of content: (NPI 1730420811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730420811 NPI number — CARROLL MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARROLL MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFEBRIDGE COMMUNITY PHYSICIAN
Provider Other Organization Name Type Code:
3
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:
1730420811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4231 N WOODS TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPSTEAD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21074-3128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-374-9391
Provider Business Mailing Address Fax Number:
410-374-1866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4231 N WOODS TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPSTEAD
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21074-3128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-374-9391
Provider Business Practice Location Address Fax Number:
410-374-1866
Provider Enumeration Date:
03/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BARRETT
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
410-374-9391

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  C0005012 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C0005012 . This is a "LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com