Provider Demographics
NPI:1861486862
Name:SPIVEY, CHARLES M (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:SPIVEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3301 FIRST STREET EAST
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474
Mailing Address - Country:US
Mailing Address - Phone:912-537-4411
Mailing Address - Fax:912-538-8485
Practice Address - Street 1:3301 FIRST STREET EAST
Practice Address - Street 2:SUITE A
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-4411
Practice Address - Fax:912-538-8485
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA047846207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA501468518EMedicaid
GA501468518EMedicaid
GA20NCCJJMedicare ID - Type Unspecified