Basic Information
| Provider Information | |||||||||
| NPI: | 1124058599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASHINGTON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5666 EAST STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611082472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152262000 | ||||||||
| FaxNumber: | 8153817582 | ||||||||
| Practice Location | |||||||||
| Address1: | 5666 EAST STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611082472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152262000 | ||||||||
| FaxNumber: | 8153817582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 53840-20 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 036109776 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 36109776 | 05 | IL | MEDICAID |