Healthcare Provider Details

I. General information

NPI: 1700873221
Provider Name (Legal Business Name): CHARLES ANTHONY SHURLOW D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 5TH ST BLDG 840, AREA B
WRIGHT PATTERSON AFB OH
45433-7951
US

IV. Provider business mailing address

2510 5TH ST BLDG 840, AREA B
WRIGHT PATTERSON AFB OH
45433-7951
US

V. Phone/Fax

Practice location:
  • Phone: 937-938-2736
  • Fax: 937-656-4006
Mailing address:
  • Phone: 937-938-2736
  • Fax: 937-656-4006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101010571
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010571
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.009947
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: