Provider Demographics
NPI:1962123554
Name:CHARTER MEDICAL GROUP
Entity type:Organization
Organization Name:CHARTER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-554-1317
Mailing Address - Street 1:2230 E FRANKLIN BLVD STE 100-227
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4982
Mailing Address - Country:US
Mailing Address - Phone:803-554-1317
Mailing Address - Fax:
Practice Address - Street 1:2550 COURT DR STE 201
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2152
Practice Address - Country:US
Practice Address - Phone:803-554-1317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1912930009Medicaid