Basic Information
| Provider Information | |||||||||
| NPI: | 1003844127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILDERS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | GILBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2231 W TAYLOR ST UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105520153 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1155 MILL ST # W11 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753275174 | ||||||||
| FaxNumber: | 7753275178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | LL3479 | NV | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2083X0100X | 125079150 | IL | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
No ID Information.