MEDICARE: MR. CHARLES ROBERT PURDY JR. RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R51609	NM
2	163W00000X	Registered Nurse	RN9245172	FL
3	163W00000X	Registered Nurse	635760	CA
4	163W00000X	Registered Nurse	2003026652	MO
5	163W00000X	Registered Nurse	1104666	KY

General Provider Information

NPI Number	:	1134374309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES ROBERT PURDY JR. RN

Provider Business Mailing Address
First Line	:	5667 MARK TRL
Second Line	:
City	:	HOUSE SPRINGS
State	:	MO
Zip	:	63051-2240
Country	:	US
Telephone Number	:	727-776-5948
Fax Number	:

Provider Business Practice Location Address
First Line	:	5667 MARK TRL
Second Line	:
City	:	HOUSE SPRINGS
State	:	MO
Zip	:	63051-2240
Country	:	US
Telephone Number	:	727-776-5948
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2008
Last Update Date	:	12/01/2008

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