Healthcare Provider Details

I. General information

NPI: 1790849180
Provider Name (Legal Business Name): CHARLES R LULL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 WAYNE RD
SAVANNAH TN
38372-1937
US

IV. Provider business mailing address

155 WILLOW ST
SAVANNAH TN
38372-3690
US

V. Phone/Fax

Practice location:
  • Phone: 504-889-0347
  • Fax: 504-779-9741
Mailing address:
  • Phone: 504-889-0347
  • Fax: 504-779-9741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD0000007740
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: