Provider Demographics
NPI:1417385246
Name:CHARLES S GINN DPM PA
Entity Type:Organization
Organization Name:CHARLES S GINN DPM PA
Other - Org Name:GINN FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:GINN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:479-531-7416
Mailing Address - Street 1:2703 SE G ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3741
Mailing Address - Country:US
Mailing Address - Phone:479-531-7416
Mailing Address - Fax:
Practice Address - Street 1:4404 W CANOPY MEADOWS DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8302
Practice Address - Country:US
Practice Address - Phone:479-531-7416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185785717Medicaid