Provider Demographics
NPI:1376743880
Name:CHARLES C WELLS
Entity Type:Organization
Organization Name:CHARLES C WELLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:C
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-536-7400
Mailing Address - Street 1:60 CHASTAIN CENTER BLVD NW
Mailing Address - Street 2:SUITE 66
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5598
Mailing Address - Country:US
Mailing Address - Phone:978-536-7400
Mailing Address - Fax:
Practice Address - Street 1:770 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2170
Practice Address - Country:US
Practice Address - Phone:478-745-5125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
915875OtherBLUE CROSS