Provider Demographics
NPI:1437363926
Name:CHARLES A LIVELY MD PA
Entity Type:Organization
Organization Name:CHARLES A LIVELY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-580-9168
Mailing Address - Street 1:608 N MUSKINGUM AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4539
Mailing Address - Country:US
Mailing Address - Phone:432-580-9168
Mailing Address - Fax:432-580-8221
Practice Address - Street 1:608 N MUSKINGUM AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4539
Practice Address - Country:US
Practice Address - Phone:432-580-9168
Practice Address - Fax:432-580-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6384207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123169807Medicaid
TXH6384OtherH6384
TX50072573OtherDPS
TX50072573OtherDPS
TXH6384OtherH6384
TXBL2122567OtherDEA