Basic Information
| Provider Information | |||||||||
| NPI: | 1073770400 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | STE 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108517423 | ||||||||
| FaxNumber: | 5108799120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207P00000X | MD2012-0479 | NM | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 50485 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M-12317 | ID | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 148073 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD178898 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 022498 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER | 22057242 | 05 | CO | MEDICAID |