Healthcare Provider Details

I. General information

NPI: 1366555369
Provider Name (Legal Business Name): PAIGE S CHARLESTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 N 190TH PLZ STE. 1100
ELKHORN NE
68022-3917
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-815-1700
  • Fax: 402-815-1959
Mailing address:
  • Phone: 402-354-2100
  • Fax: 400-235-4215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20697
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number20697
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: