Provider Demographics
NPI:1780683730
Name:ROBERT R CARROLL MD PA
Entity Type:Organization
Organization Name:ROBERT R CARROLL MD PA
Other - Org Name:ROBERT R CARROLL MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-248-2032
Mailing Address - Street 1:6400 W NEWBERRY RD
Mailing Address - Street 2:STE 206
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-6605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 W NEWBERRY RD
Practice Address - Street 2:STE 206
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-6605
Practice Address - Country:US
Practice Address - Phone:352-331-2777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24996174400000X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266485200Medicaid
GA046146600Medicaid
1020065OtherOTHER ID NUMBER
FLD40512Medicare UPIN