1316943210 NPI number — DR. CHARLES B IDOM JR. M.D., FACS

Table of content: DR. CHARLES B IDOM JR. M.D., FACS (NPI 1316943210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316943210 NPI number — DR. CHARLES B IDOM JR. M.D., FACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IDOM
Provider First Name:
CHARLES
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D., FACS
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:
1316943210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/31/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1434 BROADRICK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30720-3009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-278-5961
Provider Business Mailing Address Fax Number:
706-275-0280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1434 BROADRICK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30720-3009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-278-5961
Provider Business Practice Location Address Fax Number:
706-275-0280
Provider Enumeration Date:
06/24/2005

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: 208800000X , with the licence number:  050482 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 340019475 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00931312A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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