Healthcare Provider Details

I. General information

NPI: 1043217656
Provider Name (Legal Business Name): CHARLES R. BEASLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W 27TH ST
LUMBERTON NC
28358-3018
US

IV. Provider business mailing address

2002 N CEDAR ST STE B
LUMBERTON NC
28358-3926
US

V. Phone/Fax

Practice location:
  • Phone: 910-739-7551
  • Fax: 910-738-3764
Mailing address:
  • Phone: 910-272-3048
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number28945
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: