Basic Information
| Provider Information | |||||||||
| NPI: | 1154360378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARDOUL | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44047 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482440047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108208121 | ||||||||
| FaxNumber: | 8108208335 | ||||||||
| Practice Location | |||||||||
| Address1: | 3499 S LINDEN RD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485073022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108208121 | ||||||||
| FaxNumber: | 8108208335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 10/10/2011 | ||||||||
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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 | 207R00000X | 4301023744 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1158646 | 05 | MI | MEDICAID | 0B50683 | 01 | MI | BCBS | OTHER | EC023744 | 01 | MI | STATE LIC # | OTHER |