Provider Demographics
NPI:1538750914
Name:HANEY, CHARLES MATTHEW (RT (R)(MR))
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MATTHEW
Last Name:HANEY
Suffix:
Gender:M
Credentials:RT (R)(MR)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 597
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-0597
Mailing Address - Country:US
Mailing Address - Phone:601-604-7107
Mailing Address - Fax:
Practice Address - Street 1:2211 5TH ST STE 117
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5845
Practice Address - Country:US
Practice Address - Phone:601-621-4522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS510305261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile