Provider Demographics
NPI:1649213315
Name:HURLBURT, CHARLES PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:PHILLIP
Last Name:HURLBURT
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 1:7021 W LEE HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368-2933
Mailing Address - Country:US
Mailing Address - Phone:866-595-3662
Mailing Address - Fax:276-686-6046
Practice Address - Street 1:7021 W LEE HWY
Practice Address - Street 2:SUITE C
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368-2933
Practice Address - Country:US
Practice Address - Phone:866-595-3662
Practice Address - Fax:276-686-6046
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007610432Medicaid
VA010204968Medicaid
VA007610432Medicaid
VA010204968Medicaid
VA020978S28Medicare PIN
VACO6336Medicare PIN