Basic Information
| Provider Information | |||||||||
| NPI: | 1619478336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENNIE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | NORRIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 SHARI CT | ||||||||
| Address2: | |||||||||
| City: | HICKSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 118011813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858571889 | ||||||||
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| Practice Location | |||||||||
| Address1: | DOCTORS HOSPITAL COMMUNITY MEDICINE CLINIC | ||||||||
| Address2: | 50 OLD VILLAGE ROAD | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145441976 | ||||||||
| FaxNumber: | 6145441981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2018 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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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 | 390200000X | NY | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.