Provider Demographics
NPI:1972669612
Name:FOULSHAM, CHARLES KENNETH II (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:FOULSHAM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 117
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-0117
Mailing Address - Country:US
Mailing Address - Phone:570-748-6777
Mailing Address - Fax:570-748-0110
Practice Address - Street 1:401 HIGH STREET
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:11774-0117
Practice Address - Country:US
Practice Address - Phone:570-748-6777
Practice Address - Fax:570-748-0110
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026474E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058467OtherBLUE CROSS BLUE SHIELD
PA18639OtherGEISINGER HEALTH PLAN
PA0008614940001Medicaid
E55436Medicare UPIN
PA058467XMPMedicare PIN
PA18639OtherGEISINGER HEALTH PLAN
PA058467OtherBLUE CROSS BLUE SHIELD