Healthcare Provider Details

I. General information

NPI: 1265666515
Provider Name (Legal Business Name): CHARLES GRADY WORTMAN IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 MDG UNIT 3865
APO AE
09126-3865
US

IV. Provider business mailing address

52 MDG UNIT 3865
APO AE
09126-3865
US

V. Phone/Fax

Practice location:
  • Phone: 06575902919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: