Healthcare Provider Details

I. General information

NPI: 1053427716
Provider Name (Legal Business Name): CHARLEEN L. ISE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 PINELLAS BAYWAY STE 200
TIERRA VERDE FL
33715-1505
US

IV. Provider business mailing address

PO BOX 530968
ST PETERSBURG FL
33747-0968
US

V. Phone/Fax

Practice location:
  • Phone: 727-867-5480
  • Fax: 727-867-5470
Mailing address:
  • Phone: 727-823-2188
  • Fax: 727-828-0723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberME0055512
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberME55512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: