Provider Demographics
NPI:1306158944
Name:AMMON, CHARLES M
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:AMMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVENUE MSO PHYSICIAN BILLING
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7460
Practice Address - Street 1:146 WEST 5TH STREET
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-3734
Practice Address - Country:US
Practice Address - Phone:330-382-0165
Practice Address - Fax:330-382-0275
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN270498163WF0300X
OHAPRN.CNP.11984363LF0000X, 363LF0000X
PASP011461363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care MedicineGroup - Single Specialty
No163WF0300XNursing Service ProvidersRegistered NurseFlightGroup - Single Specialty
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023079Medicaid
OH0060646Medicaid
OH0060646Medicaid
OHH267190Medicare PIN