Provider Demographics
NPI:1114116605
Name:CHARLES J. MCMULLIN
Entity Type:Organization
Organization Name:CHARLES J. MCMULLIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARLILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-364-2227
Mailing Address - Street 1:54 HOSPITAL DR STE 205
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3050
Mailing Address - Country:US
Mailing Address - Phone:573-302-2276
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:SUITE 205
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-2276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD117270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF79542Medicare UPIN