Basic Information
| Provider Information | |||||||||
| NPI: | 1629029913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | LADY | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 485 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292020485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038988405 | ||||||||
| FaxNumber: | 8038988526 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 FAISON DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292033218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038988405 | ||||||||
| FaxNumber: | 8038988526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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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 | 207R00000X | 21596 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 215966 | 05 | SC | MEDICAID |