Basic Information
| Provider Information | |||||||||
| NPI: | 1184626483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GBUR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306588 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197947700 | ||||||||
| FaxNumber: | 4197947715 | ||||||||
| Practice Location | |||||||||
| Address1: | 5705 MONCLOVA RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | MAUMEE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435371875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197947700 | ||||||||
| FaxNumber: | 4197947715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 06/29/2009 | ||||||||
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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 | 207RC0000X | 35055676G | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 01714 | 01 | OH | PARAMOUNT | OTHER | 4951357 | 05 | MI | MEDICAID | 4951375 | 05 | MI | MEDICAID | 0671705 | 05 | OH | MEDICAID | P00334723 | 01 | OH | RRMC | OTHER | 4951384 | 05 | MI | MEDICAID | 000000476150 | 01 | OH | ANTHEM | OTHER | 4397998 | 01 | OH | AETNA | OTHER | 611448753031 | 01 | OH | CARESOURCE | OTHER |