Healthcare Provider Details

I. General information

NPI: 1922635226
Provider Name (Legal Business Name): CHARLES EADDY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 HOSPITAL DR
DOUGLASVILLE GA
30134-2266
US

IV. Provider business mailing address

1325 RALPH DAVID ABERNATHY BLVD SW
ATLANTA GA
30310-1649
US

V. Phone/Fax

Practice location:
  • Phone: 770-947-3000
  • Fax:
Mailing address:
  • Phone: 404-836-0136
  • Fax: 404-850-8695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95130
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: