Basic Information
| Provider Information | |||||||||
| NPI: | 1487604757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EFFIONG | ||||||||
| FirstName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 31093 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435730499 | ||||||||
| FaxNumber: | 8433886292 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 NASSAU ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437224112 | ||||||||
| FaxNumber: | 8435778960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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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 | 207RN0300X | 19174 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 19174 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 191740 | 05 | SC | MEDICAID | AA83436494 | 01 | SC | MEDICARE PIN FETTER HEALTH CARE NETWORK | OTHER |