Healthcare Provider Details

I. General information

NPI: 1134132657
Provider Name (Legal Business Name): CHARLES AUGUSTIN STALEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE BLDG C
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1365 CLIFTON RD NE BLDG C
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3301
  • Fax:
Mailing address:
  • Phone: 404-778-3301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number040559
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: