1790849180 NPI number — DR. CHARLES R LULL MD

Table of content: DR. CHARLES R LULL MD (NPI 1790849180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790849180 NPI number — DR. CHARLES R LULL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LULL
Provider First Name:
CHARLES
Provider Middle Name:
R
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:
1790849180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 WILLOW ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38372-3690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-889-0347
Provider Business Mailing Address Fax Number:
504-779-9741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
935 WAYNE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38372-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-889-0347
Provider Business Practice Location Address Fax Number:
504-779-9741
Provider Enumeration Date:
12/20/2006

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:  MD0000007740 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 132751 . This is a "FEDERAL BLACK LUNG" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3029154 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3093872 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1640237 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 300067251 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5001678 . This is a "MEMPHIS MANAGED CARE TLC" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000118528 . This is a "UNISON HEALTH PLAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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