Healthcare Provider Details

I. General information

NPI: 1346399581
Provider Name (Legal Business Name): CHARLES NORDELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD #130
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

308 IROQUOIS AVE
GREEN BAY WI
54301-1920
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8100
  • Fax:
Mailing address:
  • Phone: 920-437-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22478
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: