=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740312636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGE CARROLL MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 09/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 EAST SYBELIA AVE SUITE 140
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-894-9959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 EAST SYBELIA AVENUE SUITE 140
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-894-9959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GEORGE WILLIAM CARROLL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-894-9959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME48111
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------