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General NPI Number Information
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NPI Number | 1275775587
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Entity Type | Individual
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Provider Name | CHARLES NICHOLAS EISENHAUER IV M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/01/2009
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Last Update Date | 07/05/2022
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Provider Practice Location Address
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Address Line | 6029 WALNUT GROVE RD STE 404
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City | MEMPHIS
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State | TN
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Zip | 38120-2112
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Country | US
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Telephone | 901-726-1056
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Fax |
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Provider Business Mailing Address
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Address Line | 300 S BRUCE ST
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City | MARSHALL
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State | MN
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Zip | 56258-1934
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Country | US
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Telephone | 507-537-9165
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | P
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 71735
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 57079
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License Number State | TN
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