MEDICARE: CHARLES HOWARD REISDORF NP-C

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	163W00000X	Registered Nurse	4704278150	MI
2	174H00000X	Health Educator	21310526
3	363L00000X	Nurse Practitioner	4704278150	MI

General Provider Information

NPI Number	:	1922305929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES HOWARD REISDORF NP-C

Provider Business Mailing Address
First Line	:	3075 E GRAND RIVER AVE STE 112
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-6585
Country	:	US
Telephone Number	:	517-798-6766
Fax Number	:

Provider Business Practice Location Address
First Line	:	3075 E GRAND RIVER AVE STE 112
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-6585
Country	:	US
Telephone Number	:	517-798-6766
Fax Number	:

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

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	01/23/2026

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