Basic Information
| Provider Information | |||||||||
| NPI: | 1528045507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMBERS | ||||||||
| FirstName: | CARROLL | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043481855 | ||||||||
| FaxNumber: | 7043773389 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | MD 15264 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207LP3000X | 15264 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207LP3000X | 2007-01731 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207L00000X | 2007-01731 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 5911774 | 05 | NC | MEDICAID | 010990 | 05 | SC | MEDICAID | P00680393 | 01 | NC | RAILROAD-MEDICARE | OTHER |