Provider Demographics
NPI:1487627766
Name:LICHTY, CHARLES PETER II (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:PETER
Last Name:LICHTY
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SAINT VINCENTS DR STE 300
Mailing Address - Street 2:POB III
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1612
Mailing Address - Country:US
Mailing Address - Phone:205-939-4512
Mailing Address - Fax:205-939-4519
Practice Address - Street 1:833 SAINT VINCENTS DR STE 300
Practice Address - Street 2:POB III
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1612
Practice Address - Country:US
Practice Address - Phone:205-939-4512
Practice Address - Fax:205-939-4519
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00024704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL132874Medicaid
AL1487627766OtherBCBS AL
AL1487627766OtherBCBS AL
AL102I119959Medicare PIN