Basic Information
| Provider Information | |||||||||
| NPI: | 1053427716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISE | ||||||||
| FirstName: | CHARLEEN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530968 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337470968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 PINELLAS BAYWAY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TIERRA VERDE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337151505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278675480 | ||||||||
| FaxNumber: | 7278675470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0005X | ME0055512 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine | 2083P0011X | ME55512 | FL | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 267080 | 01 | AVMED | OTHER | 4045500 | 01 | AETNA | OTHER | 0100444 | 01 | EVERCARE | OTHER | 09781 | 01 | FL | BCBS | OTHER | 061978700 | 05 | FL | MEDICAID | P00306082 | 01 | RAILROAD MEDICARE | OTHER |