Healthcare Provider Details

I. General information

NPI: 1760473755
Provider Name (Legal Business Name): CHARLES L HUTCHINSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 HAWKINS STORE RD SUITE B 1
KENNESAW GA
30144
US

IV. Provider business mailing address

205 HAWKINS STORE RD SUITE B 1
KENNESAW GA
30144
US

V. Phone/Fax

Practice location:
  • Phone: 770-928-0862
  • Fax: 770-928-2286
Mailing address:
  • Phone: 770-928-0862
  • Fax: 770-928-2286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number055567
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: