Provider Demographics
NPI:1437268661
Name:CARROLL, MARIA C (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:C
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 1:550 MUNSON AVE, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-935-8717
Mailing Address - Fax:231-935-9230
Practice Address - Street 1:550 MUNSON AVE, SUITE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-935-8717
Practice Address - Fax:231-935-9230
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077553207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
M008816OtherTRICARE
MI4317989Medicaid
MI070010119OtherRAILROAD MEDICARE
MI0702803192OtherBLUE CROSS BLUE SHIELD
MI38-2170687OtherPRIORITY HEALTH
MI4317989Medicaid
MI38-2170687OtherPRIORITY HEALTH