Healthcare Provider Details

I. General information

NPI: 1518288828
Provider Name (Legal Business Name): CHARLES ROUSE CLOVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/02/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W KING ST # LL20
KINGS MOUNTAIN NC
28086-3362
US

IV. Provider business mailing address

502 W KING ST STE LL20
KINGS MOUNTAIN NC
28086-3362
US

V. Phone/Fax

Practice location:
  • Phone: 704-862-4700
  • Fax: 704-862-4749
Mailing address:
  • Phone: 704-862-4700
  • Fax: 704-862-4749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2012-00261
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number2012-00261
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2012-00261
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: