MEDICARE: DR. CHARLES MICHAEL HERNDON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RA0401X	Addiction Medicine (Internal Medicine) Physician	2370	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326062431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES MICHAEL HERNDON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 4105
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-4105
Country	:	US
Telephone Number	:	866-907-1068
Fax Number	:	425-917-9141

Provider Business Practice Location Address
First Line	:	3760 PIPER ST
Second Line	:	SUITE 1108
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-4683
Country	:	US
Telephone Number	:	907-212-6970
Fax Number	:	907-212-6971

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	09/30/2020

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