=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407181076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARROLL CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2009
-----------------------------------------------------
Last Update Date | 03/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4101 GREENBRIAR ST SUITE 208
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77098-5294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-520-6360
-----------------------------------------------------
Fax | 713-520-6363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4101 GREENBRIAR ST SUITE 208
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77098-5294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-520-6360
-----------------------------------------------------
Fax | 713-520-6363
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/OWNER
-----------------------------------------------------
Name | DR. JAMES M CARROLL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-520-6360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | M7087
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------