Provider Demographics
NPI:1063467884
Name:CHARLES W PLUMMER MD PA
Entity Type:Organization
Organization Name:CHARLES W PLUMMER MD PA
Other - Org Name:RANDY LONG, M.D., P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:H
Authorized Official - Last Name:LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-249-8760
Mailing Address - Street 1:114 W MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-6773
Mailing Address - Country:US
Mailing Address - Phone:336-249-8760
Mailing Address - Fax:336-249-2710
Practice Address - Street 1:114 W MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-6773
Practice Address - Country:US
Practice Address - Phone:336-249-8760
Practice Address - Fax:336-249-2710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24982207L00000X, 207LA0401X, 207LP2900X
207QA0401X, 207R00000X, 207RA0401X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0130LOtherBCBS PROVIDER NUMBER
NC7952594Medicaid
NC7952594Medicaid
NC7952594Medicaid