Provider Demographics
NPI:1164652970
Name:CHARLES W DAVIS II MD LLC
Entity Type:Organization
Organization Name:CHARLES W DAVIS II MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:410-335-0008
Mailing Address - Street 1:PO BOX 62440
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2440
Mailing Address - Country:US
Mailing Address - Phone:410-625-5050
Mailing Address - Fax:410-766-1404
Practice Address - Street 1:331 OAK MANOR DR
Practice Address - Street 2:SUITE 201
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5548
Practice Address - Country:US
Practice Address - Phone:410-625-5050
Practice Address - Fax:410-766-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD159276OtherMEDICARE PART B
MDDCK7CWOtherCAREFIRST
GADP4271OtherRAILROAD MEDICARE GROUP PTAN
DCQ647OtherCAREFIRST
MD417933100OtherMEDICAL ASSISTANCE