MEDICARE: MARK PHILP CARROLL JR. 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	207Q00000X	Family Medicine Physician	DR.0045118	CO

General Provider Information

NPI Number	:	1437121597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK PHILP CARROLL JR. M.D.

Provider Business Mailing Address
First Line	:	9320 GRAND CORDERA PARKWAY
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924
Country	:	US
Telephone Number	:	719-282-6337
Fax Number	:	719-282-0532

Provider Business Practice Location Address
First Line	:	9320 GRAND CORDERA PARKWAY
Second Line	:	SUITE 100
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80924
Country	:	US
Telephone Number	:	719-282-6337
Fax Number	:	719-282-0532

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	12/18/2019

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