Basic Information
| Provider Information | |||||||||
| NPI: | 1427092030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FELDT | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6401 PRAIRIE ST | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317277944 | ||||||||
| FaxNumber: | 2317247812 | ||||||||
| Practice Location | |||||||||
| Address1: | 6401 PRAIRIE ST | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317247800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 05/14/2014 | ||||||||
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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 | 207Q00000X | 5101010328 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110F163940 | 01 | MI | BCBSM | OTHER | 4829950 | 05 | MI | MEDICAID |