Provider Demographics
NPI:1205990330
Name:CARROLL, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:461 COOK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-4003
Mailing Address - Country:US
Mailing Address - Phone:706-245-1877
Mailing Address - Fax:706-245-1433
Practice Address - Street 1:461 COOK ST
Practice Address - Street 2:SUITE B
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4003
Practice Address - Country:US
Practice Address - Phone:706-245-1877
Practice Address - Fax:706-245-1433
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018369207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4505967OtherAETNA PROV NUMBER
GA975810OtherBCBS PIN NUMBER
GA975810OtherBCBS PIN NUMBER
GA16BDCWHMedicare ID - Type UnspecifiedOPTED OUT