Basic Information
| Provider Information | |||||||||
| NPI: | 1174516504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MAURA | ||||||||
| MiddleName: | KATHARINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17334 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034436717 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 20955 PROFESSIONAL PLZ | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201473405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037297652 | ||||||||
| FaxNumber: | 7037298746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 07/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0101232158 | VA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6737561 | 05 | VA | MEDICAID |