Basic Information
| Provider Information | |||||||||
| NPI: | 1972009025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADRID | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077241391 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 425 ROBINSON ST | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139041735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077241391 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2018 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | 497645 | NY | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 497645 | 01 | NY | NURSING LICENSE | OTHER |