Basic Information
| Provider Information | |||||||||
| NPI: | 1124191762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAGAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LINDBERGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD, MBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAGAN | ||||||||
| OtherFirstName: | CASS | ||||||||
| OtherMiddleName: | LINDBERGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | II | ||||||||
| OtherCredential: | MD, MBA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 732973 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177028450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1175 CARONDELET DR | ||||||||
| Address2: | |||||||||
| City: | RICHLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993543300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099439104 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | F7075 | TX | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD60020963 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1124191762 | 05 | WA | MEDICAID | 290739 | 01 | WA | L & I | OTHER | CS33807 | 01 | ID | IDAHO STATE BOARD OF PHARMACY | OTHER | G8912082 | 01 | WA | MEDICARE | OTHER | 1010553 | 05 | VT | MEDICAID | 68103 | 01 | VT | BCBS | OTHER | M-12194 | 01 | ID | STATE OF IDAHO BOARD OF MEDICINE | OTHER |