Basic Information
Provider Information | |||||||||
NPI: | 1396704516 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARROLL | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 927 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 35801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565392728 | ||||||||
FaxNumber: | 2564283423 | ||||||||
Practice Location | |||||||||
Address1: | 927 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | HUNTSVILLE | ||||||||
State: | AL | ||||||||
PostalCode: | 35801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2565392728 | ||||||||
FaxNumber: | 2564283423 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/18/2006 | ||||||||
LastUpdateDate: | 11/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA1217 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA398 | AL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 009978285 | 05 | AL |   | MEDICAID | 090219 | 01 | AL | UNITED HEALTHCARE | OTHER | 51000081 | 01 | AL | BCBS | OTHER | 7190662 | 01 | AL | AETNA | OTHER |