Individual
CHARLES WAYNE HARTZOG JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4294 LOMAC ST, MONTGOMERY, AL 36106-3604
(334) 274-9000
(334) 274-0857
Mailing address
PO BOX 370, FORTSON, GA 31808-0370
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
20880
AL
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
Primary
20880
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000032697
—
AL
05
—
000032885
—
AL
01
—
0910085
UNITED HEALTHCARE
—
01
—
200028175
RR MEDICARE
—
01
—
51032697
BLUE CROSS
—
01
—
51032885
BLUE CROSS
—
01
—
551322
PRIME HEALTH
—
01
—
5977258
AETNA
—
01
—
6455
NCC/TYNET
—
01
—
940627
FIRST HEALTH
—
Enumeration date
12/29/2005
Last updated
04/11/2023
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