Provider Demographics
NPI:1023045226
Name:JENNINGS, CHARLES D (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 15TH AVE S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-4324
Mailing Address - Country:US
Mailing Address - Phone:406-455-3650
Mailing Address - Fax:406-455-3695
Practice Address - Street 1:500 15TH AVE S
Practice Address - Street 2:SUITE 1
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-4324
Practice Address - Country:US
Practice Address - Phone:406-455-3650
Practice Address - Fax:406-455-3695
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3805174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT020013476OtherRAILROAD MEDICARE
MT0019201Medicaid
MT184609700OtherFEDERAL WORK COMP
MT000000780OtherBLUE CROSS BLUE SHIELD
MT0012575OtherWASHINGTON L&I
MT0012575OtherWASHINGTON L&I
MT020013476OtherRAILROAD MEDICARE
MTD96045Medicare UPIN