Provider Demographics
NPI:1417317264
Name:THOMAS J CARZOLI MD PA
Entity Type:Organization
Organization Name:THOMAS J CARZOLI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-765-2090
Mailing Address - Street 1:1301 TAYLOR ST
Mailing Address - Street 2:SUITE 5K
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2942
Mailing Address - Country:US
Mailing Address - Phone:803-765-2090
Mailing Address - Fax:
Practice Address - Street 1:1301 TAYLOR ST
Practice Address - Street 2:SUITE 5K
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2942
Practice Address - Country:US
Practice Address - Phone:803-765-2090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2580261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLM0039Medicaid