Provider Demographics
NPI:1699753160
Name:SHIVERS, CARROLL PAUL JR (MD)
Entity type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:PAUL
Last Name:SHIVERS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5203
Mailing Address - Country:US
Mailing Address - Phone:704-377-5772
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054441207L00000X
SC28622207L00000X
NC28622207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891162GMedicaid
SCP00893113OtherRAILROAD-MEDICARE
NCP00906978OtherRAILROAD-MEDICARE
SC28622OtherMEDICAL LICENSE
NC1162GOtherBCBSNC
SC286229Medicaid
VA010090547Medicaid
SC286229Medicaid
NC891162GMedicaid
SC5102Medicare PIN
NC1162GOtherBCBSNC
VA010090547Medicaid
VA005856A59Medicare PIN