Basic Information
| Provider Information | |||||||||
| NPI: | 1699772665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOLUMS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568681 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1735 27TH ST STE 308 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403564876 | ||||||||
| FaxNumber: | 7403566703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 34122 | KY | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 25534 | WV | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 35.133749 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3810026619 | 05 | WV | MEDICAID | 64049018 | 05 | KY | MEDICAID | 0091070 | 05 | OH | MEDICAID |