Healthcare Provider Details

I. General information

NPI: 1407174147
Provider Name (Legal Business Name): KRISTINA NICOLE CARSWELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 46TH AVE N
MYRTLE BEACH SC
29577-2732
US

IV. Provider business mailing address

115 COBBLESTONE LN
WARNER ROBINS GA
31088-8209
US

V. Phone/Fax

Practice location:
  • Phone: 478-397-0947
  • Fax:
Mailing address:
  • Phone: 843-449-1438
  • Fax: 843-286-1349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME116618
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number85877
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD39717
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: