Healthcare Provider Details

I. General information

NPI: 1184927634
Provider Name (Legal Business Name): MR. CHARLES REGINALD ELAM IV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2010
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL PKWY
DENISON IA
51442-2607
US

IV. Provider business mailing address

100 MEDICAL PKWY
DENISON IA
51442-2607
US

V. Phone/Fax

Practice location:
  • Phone: 712-265-2683
  • Fax: 712-265-2682
Mailing address:
  • Phone: 712-265-2683
  • Fax: 712-265-2682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD138067
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: