Basic Information
| Provider Information | |||||||||
| NPI: | 1215904859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRODZIN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046864411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046864411 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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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 | 207RP1001X | L0226 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 071760 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 142057203 | 05 | TX | MEDICAID | 142058002 | 05 | TX | MEDICAID | 142057204 | 05 | TX | MEDICAID | 290013827 | 01 | TX | RR MEDICARE DENTO CO | OTHER | 290013828 | 01 | TX | RR MEDICARE DALLAS CO | OTHER | 8A2490 | 01 | TX | BCBS | OTHER | 142057201 | 05 | TX | MEDICAID |