Provider Demographics
NPI:1083649461
Name:CARROLL, MARK (LPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1827
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43301-1827
Mailing Address - Country:US
Mailing Address - Phone:740-383-8022
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1050 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-383-8022
Practice Address - Fax:740-383-7942
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT004460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000206014OtherANTHEM
OH2228502Medicaid
S30454Medicare UPIN
OH2228502Medicaid