Basic Information
| Provider Information | |||||||||
| NPI: | 1801856414 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACKUS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2514 WESLEY ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376011764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238335547 | ||||||||
| FaxNumber: | 4232320238 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 HIGHWAY 11 E | ||||||||
| Address2: | |||||||||
| City: | BULLS GAP | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377113433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233934146 | ||||||||
| FaxNumber: | 4233934377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083A0300X | 1551 | TN | N | 207P00000X | DO1551 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3300057 | 05 | TN | MEDICAID |