Provider Demographics
NPI:1134132657
Name:STALEY, CHARLES AUGUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:AUGUSTIN
Last Name:STALEY
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 1:1365 CLIFTON RD NE
Mailing Address - Street 2:BLDG C
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1013
Mailing Address - Country:US
Mailing Address - Phone:404-778-3301
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:BLDG C
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0405592086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA542386OtherBCBS
GA1299416OtherUNITED HEALTHCARE
GA000664331AMedicaid
GA581116OtherUS HEALTHCARE
GA910000107OtherRAILROAD MEDICARE
GA91ZCBCCMedicare ID - Type Unspecified
GAF34710001Medicare UPIN