Provider Demographics
NPI:1851680698
Name:NINA CARROLL MD, LLC
Entity Type:Organization
Organization Name:NINA CARROLL MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-232-0202
Mailing Address - Street 1:55 POND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:617-232-0202
Mailing Address - Fax:617-739-7203
Practice Address - Street 1:55 POND AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445
Practice Address - Country:US
Practice Address - Phone:617-232-0202
Practice Address - Fax:617-739-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57518174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3027228Medicaid
MA3027228Medicaid