MEDICARE: COLONIAL CITY INTERNAL MEDICINE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	80624	OH

General Provider Information

NPI Number	:	1396769980
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLONIAL CITY INTERNAL MEDICINE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1124
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-8124
Country	:	US
Telephone Number	:	740-397-2975
Fax Number	:	740-397-3870

Provider Business Practice Location Address
First Line	:	1661 VENTURE DR
Second Line	:	SUITE A
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-8928
Country	:	US
Telephone Number	:	740-397-2915
Fax Number	:	740-397-3870

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FREDEROCL CHARLES CARROLL
Credential	:	M.D.
Telephone Number	:	740-397-2915

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	08/22/2020

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