Provider Demographics
NPI:1134122302
Name:BURNETT, CHARLES ROLAND JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROLAND
Last Name:BURNETT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:80 HUMPHREYS CTR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2361
Mailing Address - Country:US
Mailing Address - Phone:901-747-3330
Mailing Address - Fax:901-747-3245
Practice Address - Street 1:80 HUMPHREYS CTR
Practice Address - Street 2:SUITE 202
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2361
Practice Address - Country:US
Practice Address - Phone:901-747-3330
Practice Address - Fax:901-747-3245
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD014125207RC0000X
ARC-5269207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR107284001Medicaid
TN000000039811OtherTLC
MO202043303Medicaid
TN4118485OtherAETNA
MSP00372263OtherRAIL ROAD MEDICARE
62116765701OtherQUALCHOICE
TN3194515Medicaid
TN4146198OtherBCBS
AR81185OtherBCBS
MS00013823Medicaid
MO102G26OtherMO BLUE CROSS
TNP00378334OtherRAIL ROAD MEDICARE
MO102G26OtherMO BLUE CROSS
TNP00378334OtherRAIL ROAD MEDICARE
AR107284001Medicaid
TN4118485OtherAETNA