1548455884 NPI number — CHARTER MEDICAL, LLC

Table of content: (NPI 1548455884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548455884 NPI number — CHARTER MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARTER MEDICAL, LLC
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:
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:
1548455884
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 AZALEA DRIVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-533-9000
Provider Business Mailing Address Fax Number:
866-838-7780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
510 AZALEA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-533-9000
Provider Business Practice Location Address Fax Number:
866-838-7780
Provider Enumeration Date:
09/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOWEN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
662-533-9000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  07500/11.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 09458052 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com