Basic Information
| Provider Information | |||||||||
| NPI: | 1699744474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGG | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ELI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 465687 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300425687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702371089 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1727 W NEW HOPE RD | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275308114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197367908 | ||||||||
| FaxNumber: | 7702371124 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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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 | 207L00000X | 19346 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 89-36864 | 05 | NC | MEDICAID | 36864 | 01 | NC | BCBS OF NC | OTHER |