Provider Demographics
NPI:1669442869
Name:CARROLL, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:CARROLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6108 GARNERS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1401
Mailing Address - Country:US
Mailing Address - Phone:803-647-1265
Mailing Address - Fax:803-647-1266
Practice Address - Street 1:6108 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1401
Practice Address - Country:US
Practice Address - Phone:803-647-1265
Practice Address - Fax:803-647-1266
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18687208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC186872Medicaid
SC186872Medicaid