Basic Information
| Provider Information | |||||||||
| NPI: | 1770629784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REPPE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ROYAL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA13860 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2410 RUSSELL ST | ||||||||
| Address2: | APT. #C | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108431235 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 27200 CALAROGA AVE | ||||||||
| Address2: | ST. ROSE HOSPITAL | ||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945454339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102644000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | PA13860 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | PA13860 | 01 | CA | PHYSICIAN ASSISTANT | OTHER |