Healthcare Provider Details

I. General information

NPI: 1760314355
Provider Name (Legal Business Name): SAMUEL CARROLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2026
Last Update Date: 05/30/2026
Certification Date: 05/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6718 ARTHUR AVE
SAINT LOUIS MO
63139-2212
US

IV. Provider business mailing address

6718 ARTHUR AVE
SAINT LOUIS MO
63139-2212
US

V. Phone/Fax

Practice location:
  • Phone: 314-399-4599
  • Fax:
Mailing address:
  • Phone: 314-399-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB-76068
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: