Basic Information
| Provider Information | |||||||||
| NPI: | 1982665055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | READDY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S. ASHLEY DRIVE | ||||||||
| Address2: | SUITE 1500 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996220 | ||||||||
| FaxNumber: | 8138725695 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 S HABANA AVE | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138776511 | ||||||||
| FaxNumber: | 8138725695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 12/30/2013 | ||||||||
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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 | 2085R0202X | OS7332 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 251812100 | 05 | FL | MEDICAID |