Basic Information
Provider Information | |||||||||
NPI: | 1184622052 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARROLL | ||||||||
FirstName: | RAYMOND | ||||||||
MiddleName: | MCKAY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | MORRISVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 275608442 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9842154110 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1120 SE CARY PKWY | ||||||||
Address2: | SUITE 100 | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275187413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194674992 | ||||||||
FaxNumber: | 9194674339 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 05/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 200501553 | NC | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1136933 | 01 |   | AETNA HMO | OTHER | 89141P3 | 05 | NC |   | MEDICAID | 7609377 | 01 |   | AETNA PPO | OTHER | 2221221 | 01 |   | UNITED HEALTHCARE | OTHER | 141P3 | 01 |   | BCBS | OTHER |