Basic Information
| Provider Information | |||||||||
| NPI: | 1083618052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERLIN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3527 N VALDOSTA RD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292472290 | ||||||||
| FaxNumber: | 2292442626 | ||||||||
| Practice Location | |||||||||
| Address1: | 3527 N VALDOSTA RD | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292472290 | ||||||||
| FaxNumber: | 2292442626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 051543 | GA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 265002900 | 05 | FL | MEDICAID | GRP1215 | 01 | GA | MEDICARE PTAN | OTHER | 00954445A | 05 | GA | MEDICAID |