Basic Information
Provider Information | |||||||||
NPI: | 1306158944 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AMMON | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 380 SUMMIT AVENUE MSO PHYSICIAN BILLING | ||||||||
Address2: |   | ||||||||
City: | STEUBENVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 439522667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7402837597 | ||||||||
FaxNumber: | 7402837460 | ||||||||
Practice Location | |||||||||
Address1: | 146 WEST 5TH STREET | ||||||||
Address2: |   | ||||||||
City: | EAST LIVERPOOL | ||||||||
State: | OH | ||||||||
PostalCode: | 439203734 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3303820165 | ||||||||
FaxNumber: | 3303820275 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2010 | ||||||||
LastUpdateDate: | 05/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WF0300X | RN270498 | OH | N |   | Nursing Service Providers | Registered Nurse | Flight | 363LF0000X | APRN.CNP.11984 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3810023079 | 05 | WV |   | MEDICAID | 0060646 | 05 | OH |   | MEDICAID |