Provider Demographics
NPI:1417926445
Name:CARROLL, LESLIE SETON (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:SETON
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
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 828065
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-8065
Mailing Address - Country:US
Mailing Address - Phone:800-666-2455
Mailing Address - Fax:610-617-6280
Practice Address - Street 1:3401 N BROAD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-5030
Practice Address - Fax:215-707-3494
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047801L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0572020000OtherINDEPENDENCE BC
PA729722OtherHIGHMARK BS
PA0013974850005Medicaid
PA0013974850005Medicaid
F50438Medicare UPIN