Healthcare Provider Details

I. General information

NPI: 1801856414
Provider Name (Legal Business Name): CHARLES L BACKUS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/20/2023
Certification Date: 05/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 HIGHWAY 11 E
BULLS GAP TN
37711-3433
US

IV. Provider business mailing address

2514 WESLEY ST SUITE 104
JOHNSON CITY TN
37601-1764
US

V. Phone/Fax

Practice location:
  • Phone: 423-393-4146
  • Fax: 423-393-4377
Mailing address:
  • Phone: 423-833-5547
  • Fax: 423-232-0238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number1551
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO1551
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: