Healthcare Provider Details

I. General information

NPI: 1124003389
Provider Name (Legal Business Name): CHARLES MICHAEL ROESEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 12/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MOLLER AVE
SITKA AK
99835-7142
US

IV. Provider business mailing address

209 MOLLER AVE
SITKA AK
99835-7142
US

V. Phone/Fax

Practice location:
  • Phone: 907-747-1722
  • Fax: 907-747-1755
Mailing address:
  • Phone: 907-747-1722
  • Fax: 907-747-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD20793
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3878
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: