Healthcare Provider Details

I. General information

NPI: 1487117479
Provider Name (Legal Business Name): MIKE EDSON CHARLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

331 NEWMAN SPRINGS ROAD BLDG. 2, SUITE 220
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 856-803-7907
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD477764
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number25MA13148200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: