Basic Information
| Provider Information | |||||||||
| NPI: | 1588764385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | VAN | ||||||||
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| Credential: | M.D., MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9788 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049159788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102950215 | ||||||||
| FaxNumber: | 9102950218 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300467694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783121000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 01082907A | IN | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 0101039834 | VA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 20197 | GA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 2008-02090 | NC | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 14284 | WV | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 25835 | TN | N | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 5911722 | 05 | NC | MEDICAID | 0089635000 | 05 | WV | MEDICAID |