1285613570 NPI number — DR. CHARLES OTIS TUBBS MD

Table of content: DR. CHARLES OTIS TUBBS MD (NPI 1285613570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285613570 NPI number — DR. CHARLES OTIS TUBBS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUBBS
Provider First Name:
CHARLES
Provider Middle Name:
OTIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1285613570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 N LAFAYETTE ST
Provider Second Line Business Mailing Address:
SUITE 01
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28150-4444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-482-3880
Provider Business Mailing Address Fax Number:
704-487-0294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 N LAFAYETTE ST
Provider Second Line Business Practice Location Address:
SUITE 01
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28150-4444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-482-3880
Provider Business Practice Location Address Fax Number:
704-487-0294
Provider Enumeration Date:
01/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  98-00721 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E11248 . This identifiers is of the category "MEDICARE UPIN".
  • Identifier: 98-00721 . This is a "NC MEDICAL LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 131039 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13103 . This is a "SC MEDICAL LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 19736 . This is a "OKLAHOMA MEDICAL LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 11349 . This is a "NC BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2253754 . This identifiers is of the category "MEDICARE ID-TYPE UNSPECIFIED".
  • Identifier: 300089776 . This is a "RAIL ROAD MEDICARE" identifier . This identifiers is of the category "MEDICARE ID-TYPE UNSPECIFIED".
  • Identifier: 8911349 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD0000019644 . This is a "TENNESSEE MEDICAL LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: BTO748826 . This is a "DEA" identifier . This identifiers is of the category "OTHER".