Provider Demographics
NPI:1578523890
Name:FOWLKES, CARROLL H III (DO)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:H
Last Name:FOWLKES
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:955 RIBAUT RD
Mailing Address - Street 2:BMAC CREDENTIALING
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5441
Mailing Address - Country:US
Mailing Address - Phone:843-522-7843
Mailing Address - Fax:843-522-5678
Practice Address - Street 1:BEAUFORT MEMORIAL EXPRESS CARE & OCCUPATIONAL HEALTH
Practice Address - Street 2:1 BURNT CHURCH RD, STE A
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6405
Practice Address - Country:US
Practice Address - Phone:843-706-2185
Practice Address - Fax:855-299-5693
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0102049892207P00000X
SC36208207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC362084Medicaid
VA6017444Medicaid
WV0045396000Medicaid