Basic Information
| Provider Information | |||||||||
| NPI: | 1699778613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PESSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 FLEMINGSBURG RD | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 FLEMINGSBURG RD | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067805500 | ||||||||
| FaxNumber: | 6067837281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 53502 | KY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 53502 | KY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100658660 | 05 | KY | MEDICAID | 53502 | 01 | KY | KY MEDICAL LICENSE | OTHER |