Healthcare Provider Details

I. General information

NPI: 1053332841
Provider Name (Legal Business Name): CHARLES CHESLEY WELLS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 2ND ST 430
MACON GA
31201-8298
US

IV. Provider business mailing address

200 CORPORATE PL 5B
PEABODY MA
01960-3840
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-5779
  • Fax: 478-742-7796
Mailing address:
  • Phone: 978-536-7400
  • Fax: 978-536-6141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number019807
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberD19807
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: