Basic Information
| Provider Information | |||||||||
| NPI: | 1518193358 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NALLEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525670188 | ||||||||
| FaxNumber: | 8133555101 | ||||||||
| Practice Location | |||||||||
| Address1: | 2352 BRUCE B DOWNS BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | WESLEY CHAPEL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335449203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139790440 | ||||||||
| FaxNumber: | 8133555054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2009 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME132488 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | E9001 | AR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0117X | E9001 | AR | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | ME132488 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 211202001 | 05 | AR | MEDICAID | 5MM65 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER |