Basic Information
Provider Information | |||||||||
NPI: | 1437154507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARROLL | ||||||||
FirstName: | JOSIAH | ||||||||
MiddleName: | F.K. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 865 LINCOLN RD | ||||||||
Address2: | STE L10 | ||||||||
City: | BETTENDORF | ||||||||
State: | IA | ||||||||
PostalCode: | 527224159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5633559191 | ||||||||
FaxNumber: | 5633553419 | ||||||||
Practice Location | |||||||||
Address1: | 855 ILLINI DR | ||||||||
Address2: | STE 300 | ||||||||
City: | SILVIS | ||||||||
State: | IL | ||||||||
PostalCode: | 612822904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3092812050 | ||||||||
FaxNumber: | 3092812059 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 04/29/2015 | ||||||||
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 | 207Q00000X | 036071379 | IL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1508697 | 05 | IA |   | MEDICAID | 20097 | 01 |   | IOWA HEALTH SOLUTIONS | OTHER | 4796890014 | 01 |   | DMERC | OTHER | 97786 | 01 | IA | WELLMARK BC/.BS | OTHER | 036071379 | 05 | IL |   | MEDICAID | 4796890024 | 01 |   | DMERC | OTHER | 020346 | 01 |   | HEALTH ALLIANCE | OTHER | 97834 | 01 | IA | WELLMARK BC/BS | OTHER | IL0110 | 01 |   | JOHN DEERE HEALTH PLAN | OTHER |