Basic Information
| Provider Information | |||||||||
| NPI: | 1063613180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EHLENBERGER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2400 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329022400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218373820 | ||||||||
| FaxNumber: | 7726213184 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 HICKORY STREET | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214347000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 0101245945 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | MD431204 | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | ME115600 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 14PS0 | 01 | FL | FLORIDA BLUE | OTHER | 008591300 | 05 | FL | MEDICAID | P01186454 | 01 | FL | RAILROAD MEDICARE | OTHER |