Provider Demographics
NPI:1629029749
Name:CARROLL, EDMUND THOMAS III (DO)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:THOMAS
Last Name:CARROLL
Suffix:III
Gender:M
Credentials:DO
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Mailing Address - Street 1:211 EXECUTIVE DR STE 11
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-3358
Mailing Address - Country:US
Mailing Address - Phone:302-451-6913
Mailing Address - Fax:302-368-7756
Practice Address - Street 1:12100 BLACK SWAN DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-4988
Practice Address - Country:US
Practice Address - Phone:302-644-3311
Practice Address - Fax:302-644-3300
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DEC20007511207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
51-0370286OtherCORVEL/CORCARE
51-0370286OtherUNION LABOR LIFE INSURANCE COMPANY
P00247768OtherRAILROAD MEDICARE
204955OtherUNISON HEALTH PLAN
2356448000OtherAMERIHEALTH
3638665OtherAETNA US HEALTHCARE
51-0343207OtherBLUE CROSS BLUE SHIELD OF DELAWARE
51-0370286OtherGREAT-WEST HEALTHCARE
1184681488OtherCOMMERCIAL INSURANCES
2129304OtherONENET PPO, MAMSI, OPTIMUM CHOICE
DE1000035330Medicaid
51-0370286OtherDEVON HEALTH SERVICES
51-0370286OtherHEALTH NET - TRICARE/CHAMPUS
51-0370286OtherUNITED HEALTHCARE
51-0370286OtherCIGNA
51-0370286OtherUNION LABOR LIFE INSURANCE COMPANY
51-0370286OtherCIGNA
DE1000035330Medicaid