Basic Information
| Provider Information | |||||||||
| NPI: | 1497752448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWALLOW | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | 6163615828 | ||||||||
| Practice Location | |||||||||
| Address1: | 3264 N EVERGREEN DR NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495259746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163637339 | ||||||||
| FaxNumber: | 6163615828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2005 | ||||||||
| LastUpdateDate: | 05/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 260525-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 260525-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 4301501168 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100505539 | 05 | NV | MEDICAID | 924458 | 05 | AZ | MEDICAID | 8127936 | 05 | CA | MEDICAID | 120391600 | 05 | WY | MEDICAID | D1508 | 05 | UT | MEDICAID | P00651563 | 01 | UT | RR MEDICARE | OTHER | 003921900 | 05 | ID | MEDICAID | P00199656 | 01 | UT | RR MEDICARE | OTHER |