Basic Information
| Provider Information | |||||||||
| NPI: | 1629072210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEWART | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | PRESTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 COLLIER RD NW | ||||||||
| Address2: | STE 4075 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046033543 | ||||||||
| FaxNumber: | 4043508795 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 COLLIER RD NW | ||||||||
| Address2: | STE 4055 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043553200 | ||||||||
| FaxNumber: | 4043517548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 01/19/2010 | ||||||||
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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 | 207RG0100X | 054037 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 355714751A | 05 | GA | MEDICAID |