1710970595 NPI number — DR. KATHLEEN M CARROLL M.D.

Table of content: DR. KATHLEEN M CARROLL M.D. (NPI 1710970595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710970595 NPI number — DR. KATHLEEN M CARROLL M.D.

Organization/Personal Information

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

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:
1710970595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/27/2006
NPI Reactivation Date:
04/12/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
336 E BLOOMINGDALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-8155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-689-2466
Provider Business Mailing Address Fax Number:
813-689-0435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 E BLOOMINGDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-8155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-689-2466
Provider Business Practice Location Address Fax Number:
813-689-0435
Provider Enumeration Date:
08/26/2005

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: 2084P0800X , with the licence number:  ME0076947 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 79367 . This is a "BCBS ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".