Provider Demographics
NPI:1013293109
Name:CHARLES A PRENTICE MD PA
Entity Type:Organization
Organization Name:CHARLES A PRENTICE MD PA
Other - Org Name:CHARLES A PRENTICE MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-726-9006
Mailing Address - Street 1:214 S PINE AVE
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4838
Mailing Address - Country:US
Mailing Address - Phone:352-726-9006
Mailing Address - Fax:
Practice Address - Street 1:214 S PINE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4838
Practice Address - Country:US
Practice Address - Phone:352-726-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38475174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL41182Medicare PIN
FLD54719Medicare UPIN