Provider Demographics
NPI:1639152085
Name:MENDENHALL, CHARLES M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:MENDENHALL
Suffix:
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 1:425 3RD AVE
Mailing Address - Street 2:STE 50
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1955
Mailing Address - Country:US
Mailing Address - Phone:229-883-0717
Mailing Address - Fax:229-312-2257
Practice Address - Street 1:425 3RD AVE
Practice Address - Street 2:STE 50
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1955
Practice Address - Country:US
Practice Address - Phone:229-883-0717
Practice Address - Fax:229-312-2257
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA248422085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP754OtherMEDICARE GROUP
122061OtherPEACH STATE
341228OtherWELLCARE
GA00266252AMedicaid
320000060OtherRAILROAD MEDICARE
CL3407OtherRAILROAD MEDICARE GROUP