Basic Information
| Provider Information | |||||||||
| NPI: | 1629094412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINSLOW | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034328 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6169131818 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | NICU | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167526902 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 4301048835 | MI | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 4301048835 | MI | X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3473236 | 05 | MI | MEDICAID | 4877975 | 05 | MI | MEDICAID |