Basic Information
| Provider Information | |||||||||
| NPI: | 1962411090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARROLL | ||||||||
| OtherFirstName: | JOEL | ||||||||
| OtherMiddleName: | PATRICK | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6308 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531435031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626563313 | ||||||||
| FaxNumber: | 2625778399 | ||||||||
| Practice Location | |||||||||
| Address1: | 7322 236TH AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531689664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625778460 | ||||||||
| FaxNumber: | 2625778399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 24302 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 24302-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30507800 | 05 | WI | MEDICAID | K400411276 | 01 | WI | MEDICARE | OTHER | F400411291 | 01 | IL | MEDICARE (ILLINOIS) | OTHER |