Provider Demographics
NPI:1669496626
Name:LOVELADY, CHARLES BENNY (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BENNY
Last Name:LOVELADY
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1088 MIRIAM HILL DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-5967
Mailing Address - Country:US
Mailing Address - Phone:540-489-6348
Mailing Address - Fax:540-489-6595
Practice Address - Street 1:390 S MAIN ST STE 302
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1766
Practice Address - Country:US
Practice Address - Phone:540-489-6348
Practice Address - Fax:540-489-6595
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA101243927208600000X
SC16277208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL112843Medicaid
AL51049416OtherBLUE CROSS
VAVVG007AMedicare PIN
AL51049416OtherBLUE CROSS