Provider Demographics
NPI:1396769980
Name:COLONIAL CITY INTERNAL MEDICINE, INC.
Entity type:Organization
Organization Name:COLONIAL CITY INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDEROCL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-397-2915
Mailing Address - Street 1:PO BOX 1124
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-8124
Mailing Address - Country:US
Mailing Address - Phone:740-397-2975
Mailing Address - Fax:740-397-3870
Practice Address - Street 1:1661 VENTURE DR
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-8928
Practice Address - Country:US
Practice Address - Phone:740-397-2915
Practice Address - Fax:740-397-3870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH80624207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty