MEDICARE: CHARLES MATTHEW PESSON MD

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	53502	KY
2	207X00000X	Orthopaedic Surgery Physician	53502	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	53502	OTHER	KY	KY MEDICAL LICENSE

General Provider Information

NPI Number	:	1699778613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES MATTHEW PESSON MD

Provider Business Mailing Address
First Line	:	245 FLEMINGSBURG RD
Second Line	:
City	:	MOREHEAD
State	:	KY
Zip	:	40351-1015
Country	:	US
Telephone Number	:	606-780-5500
Fax Number	:	606-783-7281

Provider Business Practice Location Address
First Line	:	245 FLEMINGSBURG RD
Second Line	:
City	:	MOREHEAD
State	:	KY
Zip	:	40351-1015
Country	:	US
Telephone Number	:	606-780-5500
Fax Number	:	606-783-7281

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	04/21/2020

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