1841284270 NPI number — JANINE M CARROLL PHYSICIAN ASSISTANT

Table of content: JANINE M CARROLL PHYSICIAN ASSISTANT (NPI 1841284270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841284270 NPI number — JANINE M CARROLL PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
JANINE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
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:
1841284270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
332 DEWEY STREET
Provider Second Line Business Mailing Address:
TACONIC ORTHOPEDICS PC
Provider Business Mailing Address City Name:
BENNINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-442-6314
Provider Business Mailing Address Fax Number:
802-447-1686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
332 DEWEY STREET
Provider Second Line Business Practice Location Address:
TACONIC ORTHOPEDICS PC
Provider Business Practice Location Address City Name:
BENNINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-442-6314
Provider Business Practice Location Address Fax Number:
802-447-1686
Provider Enumeration Date:
08/31/2005

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: 363A00000X , with the licence number:  0550030203 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 055-0030203 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0005117 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 635529 . This is a "MVP" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 9000271 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200010961 . This is a "RAILROAD MEDICARE/ PALMETTO" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: GRTH18953 . This is a "BC/BS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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