Basic Information
| Provider Information | |||||||||
| NPI: | 1457321853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEALL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 E HOUSTON ST | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035927393 | ||||||||
| FaxNumber: | 9035977538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 12/08/2014 | ||||||||
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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 | 208600000X | H6039 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 122995 | 01 | TX | SUPERIOR/CHIPS | OTHER | 4523320 | 01 | TX | AETNA | OTHER | 099323002 | 05 | TX | MEDICAID | 83Y705 | 01 | TX | BCBS | OTHER |