Basic Information
| Provider Information | |||||||||
| NPI: | 1275775587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EISENHAUER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 S BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562581934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075379165 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6029 WALNUT GROVE RD STE 404 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017261056 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2009 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | P | KY | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 71735 | MN | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 57079 | TN | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 57079 | 01 | TN | TN STATE LICENSE | OTHER | 48491 | 01 | KY | KY STATE LICENSE | OTHER | 0148667 | 05 | OH | MEDICAID | 7100133120 | 05 | KY | MEDICAID |