Basic Information
| Provider Information | |||||||||
| NPI: | 1952388050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARTZOG | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235003 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342749000 | ||||||||
| FaxNumber: | 3342740857 | ||||||||
| Practice Location | |||||||||
| Address1: | 4294 LOMAC ST | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361063604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342749000 | ||||||||
| FaxNumber: | 3342740857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 06/24/2008 | ||||||||
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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 | 207X00000X | 20880 | AL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 20880 | AL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000032697 | 05 | AL | MEDICAID | 200028175 | 01 | RR MEDICARE | OTHER | 51032885 | 01 | BLUE CROSS | OTHER | 551322 | 01 | PRIME HEALTH | OTHER | 0910085 | 01 | UNITED HEALTHCARE | OTHER | 940627 | 01 | FIRST HEALTH | OTHER | 000032885 | 05 | AL | MEDICAID | 51032697 | 01 | BLUE CROSS | OTHER | 5977258 | 01 | AETNA | OTHER | 6455 | 01 | NCC/TYNET | OTHER |