Provider Demographics
NPI:1366578197
Name:CARROLL, BRONWEN C (MD)
Entity type:Individual
Prefix:
First Name:BRONWEN
Middle Name:C
Last Name:CARROLL
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Gender:F
Credentials:MD
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Mailing Address - Street 1:BMC PROVIDER ENROLLMENT OFFICE
Mailing Address - Street 2:960 MASSACHUSETTS AVE,.2ND FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 HARRISON AVE
Practice Address - Street 2:MENINO 1
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-414-4991
Practice Address - Fax:617-414-4999
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2024-04-03
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Provider Licenses
StateLicense IDTaxonomies
MA237078208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110082537AMedicaid
MA1117501Medicare PIN