Healthcare Provider Details

I. General information

NPI: 1225007016
Provider Name (Legal Business Name): CHARLES P HOUSE SR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MCPHERSON HWY
CLYDE OH
43410-1133
US

IV. Provider business mailing address

PO BOX 179
BELLEVUE OH
44811-0179
US

V. Phone/Fax

Practice location:
  • Phone: 419-547-0584
  • Fax: 419-547-8918
Mailing address:
  • Phone: 440-274-5000
  • Fax: 440-716-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-007179
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: