Provider Demographics
NPI:1073728275
Name:PETERMAN, CHARLES EMERSON III (ATC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EMERSON
Last Name:PETERMAN
Suffix:III
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 21ST AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-5035
Mailing Address - Country:US
Mailing Address - Phone:727-452-4283
Mailing Address - Fax:
Practice Address - Street 1:4600 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-3802
Practice Address - Country:US
Practice Address - Phone:727-369-5039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8492255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer