Healthcare Provider Details

I. General information

NPI: 1609087121
Provider Name (Legal Business Name): BRYAN CARROLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 CLAGUE RD BLDG B
WESTLAKE OH
44145-1533
US

IV. Provider business mailing address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-8200
  • Fax: 440-250-2022
Mailing address:
  • Phone: 216-844-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101252291
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.137019
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: