Healthcare Provider Details

I. General information

NPI: 1871586917
Provider Name (Legal Business Name): ANNE CHARLOTTE SQUIRES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W MAIN ST
ABINGDON VA
24210-2715
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 276-676-3870
  • Fax: 276-628-8927
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101223782
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number47033
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number47033
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: