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1497752448

NPI Code Detail

MEDICARE: DR. CHARLES EDWARD SWALLOW M.D.

MEDICARE: DR. CHARLES EDWARD SWALLOW M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085N0700X	Neuroradiology Physician	260525-1205	UT
2	2085R0202X	Diagnostic Radiology Physician	260525-1205	UT
3	2085R0202X	Diagnostic Radiology Physician	4301501168	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	P00651563	OTHER	UT	RR MEDICARE
8	P00199656	OTHER	UT	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497752448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES EDWARD SWALLOW M.D.

Provider Business Mailing Address
First Line	:	3264 N EVERGREEN DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9746
Country	:	US
Telephone Number	:	616-363-7339
Fax Number	:	616-361-5828

Provider Business Practice Location Address
First Line	:	3264 N EVERGREEN DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9746
Country	:	US
Telephone Number	:	616-363-7339
Fax Number	:	616-361-5828

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	05/04/2020

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Directions to “ DR. CHARLES EDWARD SWALLOW M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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