=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164676771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DJRJ2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2008
-----------------------------------------------------
Last Update Date | 11/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4225 NW AMERICAN LN
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32055-8841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-365-3845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 805
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32056-0805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-755-9190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH MICHAEL CHARL3S JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 386-365-3845
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | ME82558
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------