Basic Information
Provider Information | |||||||||
NPI: | 1225060148 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARROLL | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | BRUCE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 27 | ||||||||
Address2: |   | ||||||||
City: | BAKERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 287050027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286882104 | ||||||||
FaxNumber: | 8286881334 | ||||||||
Practice Location | |||||||||
Address1: | 86 N MITCHELL AVE | ||||||||
Address2: |   | ||||||||
City: | BAKERSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 287056502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286882104 | ||||||||
FaxNumber: | 8286881334 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2006 | ||||||||
LastUpdateDate: | 08/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31781 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 07673 | 01 | NC | BCBS PHYSICIAN | OTHER | 8907673 | 01 | NC | MEDCAID PHYSICIAN | OTHER | 8921331 | 05 | NC |   | MEDICAID | 411013849 | 01 | NC | MEDICARE RAILROAD | OTHER | 00513 | 01 | NC | BCBS | OTHER | 212036D | 01 | NC | MEDICARE PIN | OTHER | 3400011 | 01 | NC | MEDCAID | OTHER | 014MX | 01 | NC | BCBS LABS | OTHER | 235013B | 01 | NC | MEDICARE PHYSICIAN | OTHER | 235013 | 01 | NC | MEDICARE PHYSICIAN | OTHER |