Provider Demographics
NPI:1730153636
Name:CARROLL, MARY ELIZABET (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABET
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 CONIFER CT.
Mailing Address - Street 2:
Mailing Address - City:GLEN ARM
Mailing Address - State:MD
Mailing Address - Zip Code:21057-9124
Mailing Address - Country:US
Mailing Address - Phone:410-882-5064
Mailing Address - Fax:
Practice Address - Street 1:9110 PHILADELPHIA RD.
Practice Address - Street 2:STE. 108
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-4301
Practice Address - Country:US
Practice Address - Phone:410-574-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0028177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD367471100Medicaid
MD367471100Medicaid
MDMD2157Medicare ID - Type Unspecified