Healthcare Provider Details

I. General information

NPI: 1437154507
Provider Name (Legal Business Name): JOSIAH F.K. CARROLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 ILLINI DR STE 300
SILVIS IL
61282-2904
US

IV. Provider business mailing address

865 LINCOLN RD STE L10
BETTENDORF IA
52722-4159
US

V. Phone/Fax

Practice location:
  • Phone: 309-281-2050
  • Fax: 309-281-2059
Mailing address:
  • Phone: 563-355-9191
  • Fax: 563-355-3419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036071379
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: