1639152085 NPI number — DR. CHARLES M MENDENHALL MD

Table of content: DR. CHARLES M MENDENHALL MD (NPI 1639152085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639152085 NPI number — DR. CHARLES M MENDENHALL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDENHALL
Provider First Name:
CHARLES
Provider Middle Name:
M
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:
1639152085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 3RD AVE
Provider Second Line Business Mailing Address:
STE 50
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31701-1955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-883-0717
Provider Business Mailing Address Fax Number:
229-312-2257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 3RD AVE
Provider Second Line Business Practice Location Address:
STE 50
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31701-1955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-883-0717
Provider Business Practice Location Address Fax Number:
229-312-2257
Provider Enumeration Date:
11/21/2005

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: 2085R0001X , with the licence number:  24842 , 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: GRP754 . This is a "MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 122061 . This is a "PEACH STATE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 341228 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00266252A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 320000060 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: CL3407 . This is a "RAILROAD MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".




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