Provider Demographics
NPI:1275209488
Name:SOUTHERLY, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SOUTHERLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 PIN OAK RD
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:WV
Mailing Address - Zip Code:25434-3252
Mailing Address - Country:US
Mailing Address - Phone:304-822-0390
Mailing Address - Fax:
Practice Address - Street 1:1165 PIN OAK RD
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:WV
Practice Address - Zip Code:25434-3252
Practice Address - Country:US
Practice Address - Phone:304-822-0390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker