Provider Demographics
NPI:1689647679
Name:COLLINS, CHARLES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:COLLINS
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:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7602
Mailing Address - Fax:843-662-2474
Practice Address - Street 1:204 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2604
Practice Address - Country:US
Practice Address - Phone:843-777-7602
Practice Address - Fax:843-662-2474
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11594208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC115949Medicaid