MEDICARE: DR. BRENDA ANN CARROLL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	053433	GA
2	207RH0003X	Hematology & Oncology Physician	41749	AZ
3	2083X0100X	Occupational Medicine Physician	15060	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	52053633	OTHER	GA	BCBS

General Provider Information

NPI Number	:	1396739595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENDA ANN CARROLL M.D.

Provider Business Mailing Address
First Line	:	1723 LAKEVIEW AVE
Second Line	:
City	:	CAMDEN
State	:	SC
Zip	:	29020-2728
Country	:	US
Telephone Number	:	928-750-2891
Fax Number	:

Provider Business Practice Location Address
First Line	:	643 HIGHWAY 1 S
Second Line	:
City	:	LUGOFF
State	:	SC
Zip	:	29078-9174
Country	:	US
Telephone Number	:	928-750-2891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	07/12/2024

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