Provider Demographics
NPI:1952388050
Name:HARTZOG, CHARLES WAYNE JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WAYNE
Last Name:HARTZOG
Suffix:JR
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 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4294 LOMAC ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-3604
Practice Address - Country:US
Practice Address - Phone:334-274-9000
Practice Address - Fax:334-274-0857
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20880207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000032697Medicaid
AL000032885Medicaid
200028175OtherRR MEDICARE
6455OtherNCC/TYNET
940627OtherFIRST HEALTH
0910085OtherUNITED HEALTHCARE
551322OtherPRIME HEALTH
5977258OtherAETNA
51032697OtherBLUE CROSS
51032885OtherBLUE CROSS
200028175OtherRR MEDICARE
6455OtherNCC/TYNET
F93837Medicare UPIN
5977258OtherAETNA
AL000032885Medicaid
H431Medicare PIN
940627OtherFIRST HEALTH
I048Medicare PIN
J030Medicare PIN