Provider Demographics
NPI:1336258045
Name:CARROLL, LARRY J (CRNA, APN)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:J
Last Name:CARROLL
Suffix:
Gender:M
Credentials:CRNA, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 E FORK DR
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62471-3818
Mailing Address - Country:US
Mailing Address - Phone:618-283-0233
Mailing Address - Fax:
Practice Address - Street 1:904 W TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2178
Practice Address - Country:US
Practice Address - Phone:217-342-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL958110Medicare UPIN
ILK02649Medicare ID - Type UnspecifiedEASTC MEDICARE #