Healthcare Provider Details

I. General information

NPI: 1235076480
Provider Name (Legal Business Name): CHARLES RICHARD SOUTHWELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GENESYS PARKWAY, GRAND BLANC, MI 48439
GRAND BLANC MI
48439
US

IV. Provider business mailing address

GENESYS PARKWAY, GRAND BLANC, MI 48439
GRAND BLANC MI
48439
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5151017881
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: