Healthcare Provider Details

I. General information

NPI: 1083015630
Provider Name (Legal Business Name): MARY ELIZABETH CHARLESTON P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-2802
  • Fax: 616-391-2840
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008287
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: