1649381344 NPI number — LISA BERTINA CARROLL PA C

Table of content: LISA BERTINA CARROLL PA C (NPI 1649381344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649381344 NPI number — LISA BERTINA CARROLL PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
LISA
Provider Middle Name:
BERTINA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
LISA
Provider Other Middle Name:
BERTINA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649381344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6201 GREENLEIGH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLE RIVER
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21220-2004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
109-330-0000
Provider Business Mailing Address Fax Number:
410-500-4266

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2051 HAMILL ROAD
Provider Second Line Business Practice Location Address:
STE 301 A
Provider Business Practice Location Address City Name:
HIXSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-870-3376
Provider Business Practice Location Address Fax Number:
423-877-1387
Provider Enumeration Date:
08/31/2006

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:  PA0000001158 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: C0009929 , 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)