Healthcare Provider Details

I. General information

NPI: 1164652970
Provider Name (Legal Business Name): CHARLES W DAVIS II MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 OAK MANOR DR SUITE 201
GLEN BURNIE MD
21061-5548
US

IV. Provider business mailing address

PO BOX 62440
BALTIMORE MD
21264-2440
US

V. Phone/Fax

Practice location:
  • Phone: 410-625-5050
  • Fax: 410-766-1404
Mailing address:
  • Phone: 410-625-5050
  • Fax: 410-766-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: CHARLES W DAVIS II
Title or Position: SOLE MANAGER
Credential: M.D.
Phone: 410-335-0008