Provider Demographics
NPI:1952342024
Name:CARROLL, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
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 1:114 TOWNPARK DR NW
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3715
Mailing Address - Country:US
Mailing Address - Phone:770-952-8612
Mailing Address - Fax:678-803-6944
Practice Address - Street 1:1150 HAMMOND DR NE
Practice Address - Street 2:BUILDING E SUITE 350
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5334
Practice Address - Country:US
Practice Address - Phone:404-252-4207
Practice Address - Fax:404-303-2758
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015537207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA03BDBPTMedicare ID - Type Unspecified
D45011Medicare UPIN