Basic Information
| Provider Information | |||||||||
| NPI: | 1912913716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REIDHEAD | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | TYLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REIDHEAD | ||||||||
| OtherFirstName: | C | ||||||||
| OtherMiddleName: | TY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 860 | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859410860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283381122 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 W. HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITERIVER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283384911 | ||||||||
| FaxNumber: | 9283381122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 12/15/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25107 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1780614008 | 05 | AZ | MEDICAID | 1295993376 | 05 | AZ | MEDICAID | 1629236716 | 05 | AZ | MEDICAID | 1871523191 | 05 | AZ | MEDICAID | 409856 | 05 | AZ | MEDICAID |