Basic Information
| Provider Information | |||||||||
| NPI: | 1790821122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 823 CENTER AVE | ||||||||
| Address2: | P.O. BOX 175 | ||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836612535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086423396 | ||||||||
| FaxNumber: | 2086429060 | ||||||||
| Practice Location | |||||||||
| Address1: | 823 CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836612535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086423396 | ||||||||
| FaxNumber: | 2086429060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M-4116 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000010005775 | 01 | REGENCE BLUE SHIELD | OTHER | R108734 | 01 | MEDICARE-NORIDIAN | OTHER | 003636500 | 05 | ID | MEDICAID | 73437 | 01 | BLUE CROSS | OTHER | 820525763 | 01 | COMMERCIAL | OTHER | 231902 | 05 | OR | MEDICAID | D80174720 | 01 | MEDICARE- RAILROAD | OTHER |