Healthcare Provider Details

I. General information

NPI: 1851680698
Provider Name (Legal Business Name): NINA CARROLL MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 POND AVENUE
BROOKLINE MA
02445
US

IV. Provider business mailing address

55 POND AVENUE
BROOKLINE MA
02445
US

V. Phone/Fax

Practice location:
  • Phone: 617-232-0202
  • Fax: 617-739-7203
Mailing address:
  • Phone: 617-232-0202
  • Fax: 617-739-7203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number57518
License Number StateMA

VIII. Authorized Official

Name: DR. NINA M CARROLL
Title or Position: PRESIDENT
Credential: MD
Phone: 617-232-0202