Basic Information
| Provider Information | |||||||||
| NPI: | 1265619365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6006 49TH ST N | ||||||||
| Address2: | STE 310 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337092148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275279779 | ||||||||
| FaxNumber: | 7275220415 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 S MOON AVE | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135719988 | ||||||||
| FaxNumber: | 8135719922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 002604 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | ME113143 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 012769800 | 05 | FL | MEDICAID |