Basic Information
| Provider Information | |||||||||
| NPI: | 1578523890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLKES | ||||||||
| FirstName: | CARROLL | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | BMAC CREDENTIALING | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435227843 | ||||||||
| FaxNumber: | 8435225678 | ||||||||
| Practice Location | |||||||||
| Address1: | BEAUFORT MEMORIAL EXPRESS CARE & OCCUPATIONAL HEALTH | ||||||||
| Address2: | 1 BURNT CHURCH RD, STE A | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299106405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437062185 | ||||||||
| FaxNumber: | 8552995693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0102049892 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 36208 | SC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 362084 | 05 | SC | MEDICAID | 6017444 | 05 | VA | MEDICAID | 0045396000 | 05 | WV | MEDICAID |