Basic Information
| Provider Information | |||||||||
| NPI: | 1962484915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 277730 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303847730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1802 BRAEBURN DR | ||||||||
| Address2: | SUITE 1310 | ||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241537357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407762020 | ||||||||
| FaxNumber: | 5407762017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 03/20/2009 | ||||||||
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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 | 363AS0400X | 0110840469 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00413631 | 01 | MEDICARE RR | OTHER | 1962484915 | 05 | VA | MEDICAID | P00453914 | 01 | VA | RAILROAD MEDICARE | OTHER |