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General NPI Number Information
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NPI Number | 1801856414
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Entity Type | Individual
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Provider Name | CHARLES L BACKUS DO
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Gender | Male
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Dates
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Enumeration Date | 03/27/2006
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Last Update Date | 09/20/2023
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Provider Practice Location Address
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Address Line | 273 HIGHWAY 11 E
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City | BULLS GAP
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State | TN
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Zip | 37711-3433
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Country | US
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Telephone | 423-393-4146
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Fax | 423-393-4377
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Provider Business Mailing Address
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Address Line | 2514 WESLEY ST SUITE 104
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City | JOHNSON CITY
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State | TN
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Zip | 37601-1764
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Country | US
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Telephone | 423-833-5547
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Fax | 423-232-0238
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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 | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number | 1551
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | DO1551
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License Number State | TN
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