Provider Demographics
NPI:1275775587
Name:EISENHAUER, CHARLES NICHOLAS IV (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:NICHOLAS
Last Name:EISENHAUER
Suffix:IV
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 1:300 S BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1934
Mailing Address - Country:US
Mailing Address - Phone:507-537-9165
Mailing Address - Fax:
Practice Address - Street 1:6029 WALNUT GROVE RD STE 404
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-726-1056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP208600000X
MN71735208600000X
TN57079208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN57079OtherTN STATE LICENSE
KY48491OtherKY STATE LICENSE
OH0148667Medicaid
KY7100133120Medicaid