Basic Information
| Provider Information | |||||||||
| NPI: | 1063505139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S HARBOUR ISLAND BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273223439 | ||||||||
| FaxNumber: | 8009287449 | ||||||||
| Practice Location | |||||||||
| Address1: | 1931 TAMIAMI TRL STE 4-6 | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339482181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418880560 | ||||||||
| FaxNumber: | 8443886186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25717 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000050440 | 01 | ANTHEM | OTHER |