1780737833 NPI number — CHARLES R BURNETT, JR.

Table of content: (NPI 1780737833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780737833 NPI number — CHARLES R BURNETT, JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES R BURNETT, JR.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHARLES R. BURNETT, MD
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780737833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 38188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GERMANTOWN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38183-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-755-4306
Provider Business Mailing Address Fax Number:
901-755-4307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 HUMPHREYS CTR
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-2368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-747-3530
Provider Business Practice Location Address Fax Number:
901-755-4307
Provider Enumeration Date:
01/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURNETT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
BUSINESS ADMINISTRATOR
Authorized Official Telephone Number:
901-755-4306

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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