Healthcare Provider Details

I. General information

NPI: 1649213315
Provider Name (Legal Business Name): CHARLES PHILLIP HURLBURT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7021 W LEE HWY SUITE C
RURAL RETREAT VA
24368-2933
US

IV. Provider business mailing address

7021 W LEE HWY SUITE C
RURAL RETREAT VA
24368-2933
US

V. Phone/Fax

Practice location:
  • Phone: 866-595-3662
  • Fax: 276-686-6046
Mailing address:
  • Phone: 866-595-3662
  • Fax: 276-686-6046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101048104
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: