=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164652970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES W DAVIS II MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2009
-----------------------------------------------------
Last Update Date | 11/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 OAK MANOR DR SUITE 201
-----------------------------------------------------
City | GLEN BURNIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21061-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-625-5050
-----------------------------------------------------
Fax | 410-766-1404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 62440
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21264-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-625-5050
-----------------------------------------------------
Fax | 410-766-1404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MANAGER
-----------------------------------------------------
Name | CHARLES W DAVIS II
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 410-335-0008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------