MEDICARE: DR. CHARLES ANTHONY SHURLOW 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	207P00000X	Emergency Medicine Physician	5101010571	MI
2	207Q00000X	Family Medicine Physician	5101010571	MI
3	207P00000X	Emergency Medicine Physician	34.009947	OH

General Provider Information

NPI Number	:	1700873221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES ANTHONY SHURLOW D.O.

Provider Business Mailing Address
First Line	:	2510 5TH ST
Second Line	:	BLDG 840, AREA B
City	:	WRIGHT PATTERSON AFB
State	:	OH
Zip	:	45433-7951
Country	:	US
Telephone Number	:	937-938-2736
Fax Number	:	937-656-4006

Provider Business Practice Location Address
First Line	:	2510 5TH ST
Second Line	:	BLDG 840, AREA B
City	:	WRIGHT PATTERSON AFB
State	:	OH
Zip	:	45433-7951
Country	:	US
Telephone Number	:	937-938-2736
Fax Number	:	937-656-4006

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	11/08/2011

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