Basic Information
| Provider Information | |||||||||
| NPI: | 1588629216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6255 SHERIDAN DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142214836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578666 | ||||||||
| FaxNumber: | 7168578944 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578641 | ||||||||
| FaxNumber: | 7168563002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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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 | 213322 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00020553501 | 01 | NY | UNIVERA | OTHER | 161000580 | 01 | NY | EMPIRE | OTHER | 000525766003 | 01 | NY | HEALTH NOW | OTHER | 0410829 | 01 | NY | IHA | OTHER | 213322-1W | 01 | NY | WORKERS COMPENSATION | OTHER | 161000580 | 01 | NY | NORTH AMERICAN PREFERRED | OTHER | 01991868 | 05 | NY | MEDICAID |