Provider Demographics
NPI:1730420811
Name:CARROLL MEDICAL GROUP
Entity type:Organization
Organization Name:CARROLL MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:410-374-9391
Mailing Address - Street 1:4231 N WOODS TRL
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-3128
Mailing Address - Country:US
Mailing Address - Phone:410-374-9391
Mailing Address - Fax:410-374-1866
Practice Address - Street 1:4231 N WOODS TRL
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074-3128
Practice Address - Country:US
Practice Address - Phone:410-374-9391
Practice Address - Fax:410-374-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005012363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0005012OtherLICENSE