Provider Demographics
NPI:1942229299
Name:CARROLL, SCOTT K (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:K
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 1:37 CALUMET PKWY
Mailing Address - Street 2:#F STE 103
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-6734
Mailing Address - Country:US
Mailing Address - Phone:770-253-3006
Mailing Address - Fax:770-253-1440
Practice Address - Street 1:60 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1210
Practice Address - Country:US
Practice Address - Phone:770-253-2330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0277792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00327808EMedicaid
GA58-1440934OtherTAX EIN
GA00327808EMedicaid
GAD45011Medicare UPIN