Healthcare Provider Details

I. General information

NPI: 1962411090
Provider Name (Legal Business Name): JOEL CARROLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOEL PATRICK CARROLL MD

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7322 236TH AVE
SALEM WI
53168-9664
US

IV. Provider business mailing address

6308 8TH AVE
KENOSHA WI
53143-5031
US

V. Phone/Fax

Practice location:
  • Phone: 262-577-8460
  • Fax: 262-577-8399
Mailing address:
  • Phone: 262-656-3313
  • Fax: 262-577-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number24302
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24302-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: