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General NPI Number Information
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NPI Number | 1629280359
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Entity Type | Organization
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Legal Business Name | CHARLES P. LAWLESS, M.D., P.A.
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 12/03/2007
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Provider Practice Location Address
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Address Line | 1777 E CLARK ST STE 310
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City | POCATELLO
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State | ID
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Zip | 83201-3357
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Country | US
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Telephone | 208-232-4133
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Fax | 208-233-5736
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Provider Business Mailing Address
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Address Line | 1777 E CLARK ST STE 310
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City | POCATELLO
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State | ID
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Zip | 83201-3357
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Country | US
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Telephone | 208-232-4133
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Fax | 208-233-5736
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES PITTMAN LAWLESS
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Credential | M.D.
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Telephone | 208-232-4133
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M-3434
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License Number State | ID
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