Provider Demographics
NPI:1265484547
Name:CHARLES, SAMUEL G (DC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:CHARLES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5932
Mailing Address - Country:US
Mailing Address - Phone:410-398-2108
Mailing Address - Fax:410-398-1460
Practice Address - Street 1:139 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5932
Practice Address - Country:US
Practice Address - Phone:410-398-2108
Practice Address - Fax:410-398-1460
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01301111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
T59540Medicare UPIN
M134Medicare ID - Type Unspecified