Healthcare Provider Details

I. General information

NPI: 1154550390
Provider Name (Legal Business Name): CHARLES JOHN USSERY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N PATTERSON ST SOUTH GEORGIA MEDICAL CENTER
VALDOSTA GA
31602-1735
US

IV. Provider business mailing address

PO BOX 2278
RICHMOND HILL GA
31324-2278
US

V. Phone/Fax

Practice location:
  • Phone: 229-333-1110
  • Fax:
Mailing address:
  • Phone: 229-333-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number67622
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number55810-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: