Basic Information
| Provider Information | |||||||||
| NPI: | 1437158409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARRON | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2446 LAUREL ROAD | ||||||||
| Address2: | |||||||||
| City: | N. VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412186200 | ||||||||
| FaxNumber: | 9412186182 | ||||||||
| Practice Location | |||||||||
| Address1: | 2446 LAUREL RD E | ||||||||
| Address2: | |||||||||
| City: | NORTH VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342753204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412186200 | ||||||||
| FaxNumber: | 9412186182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD426949 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | MD426949 | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | ME127208 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 171877 | 01 | NY | UNISON | OTHER | 707502 | 01 | PA | UPMC | OTHER | 00027311601 | 01 | NY | UNIVERA | OTHER | 02702716 | 01 | NY | NY MEDICAL ASSISTANCE | OTHER | 1013438520001 | 05 | PA | MEDICAID | 2581880 | 01 | OH | OH MEDICAL ASSISTANCE | OTHER | 489732 | 01 | PA | BLUE SHIELD | OTHER | 1068852 | 01 | WV | WEST VIRGINIA WORK COMP | OTHER | 1546470 | 01 | PA | GATEWAY | OTHER | 3953000 | 01 | PA | AETNA | OTHER | P00310036 | 01 | PA | RR MEDICARE | OTHER |