MEDICARE: DR. CHARLEY T. MYRICK III D. O.

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	2085R0202X	Diagnostic Radiology Physician	OS8935	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71825	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457342727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLEY T. MYRICK III D. O.

Provider Business Mailing Address
First Line	:	2125 CRYSTAL GROVE DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-6875
Country	:	US
Telephone Number	:	863-688-2334
Fax Number	:	863-577-0299

Provider Business Practice Location Address
First Line	:	2125 CRYSTAL GROVE DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-6875
Country	:	US
Telephone Number	:	863-688-2334
Fax Number	:	863-577-0299

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

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	09/26/2013

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