Basic Information
| Provider Information | |||||||||
| NPI: | 1396739595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283172518 | ||||||||
| FaxNumber: | 9283734206 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 W 24TH ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853646233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283172518 | ||||||||
| FaxNumber: | 9283734206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 053433 | GA | N | Other Service Providers | Specialist | 207RH0003X | 41749 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 52053633 | 01 | GA | BCBS | OTHER | 893096988A | 05 | GA | MEDICAID |