Basic Information
| Provider Information | |||||||||
| NPI: | 1295905073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARON MEDICAL CLINIC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11638 HIGHWAY 27 | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | SUMMERVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307478514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068572133 | ||||||||
| FaxNumber: | 7068572139 | ||||||||
| Practice Location | |||||||||
| Address1: | 11638 HIGHWAY 27 | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | SUMMERVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307478514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068572133 | ||||||||
| FaxNumber: | 7068572139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 03/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARON | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7068572133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 046377 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Community Health Worker |
No ID Information.