Basic Information
| Provider Information | |||||||||
| NPI: | 1922113539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REISEN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 HADDONFIELD BERLIN RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567822212 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087015237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323631900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| 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 | 2080N0001X | 25MA05286100 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5233101 | 05 | NJ | MEDICAID |