Provider Demographics
NPI:1912903774
Name:ELLISON, CARROL WENDALL (MD)
Entity Type:Individual
Prefix:MR
First Name:CARROL
Middle Name:WENDALL
Last Name:ELLISON
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 1:500 EAST PARKER RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655
Mailing Address - Country:US
Mailing Address - Phone:828-433-5700
Mailing Address - Fax:828-433-5702
Practice Address - Street 1:500 EAST PARKER RD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655
Practice Address - Country:US
Practice Address - Phone:828-433-5700
Practice Address - Fax:828-433-5702
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19994207V00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8930648Medicaid
NCC85277Medicare UPIN
NC201614AMedicare PIN
NC8930648Medicaid