Basic Information
| Provider Information | |||||||||
| NPI: | 1568425668 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MARION | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 HOMEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441071420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162286526 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168441000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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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 | 207P00000X | 35060690 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000212469 | 01 | OH | UNISON | OTHER | 000000503545 | 01 | OH | ANTHEM | OTHER | 363398 | 01 | OH | WELLCARE MEDICAID | OTHER | 742629 | 01 | OH | BUCKEYE MEDICAID | OTHER | 000000379823 | 01 | OH | ANTHEM | OTHER | 4405802 | 01 | OH | AETNA | OTHER | 0823238 | 05 | OH | MEDICAID | N363376 | 01 | OH | WELLCARE | OTHER | P00382874 | 01 | OH | RAILROAD MEDICARE | OTHER |