Provider Demographics
NPI:1053440669
Name:ZACHEM, CHARLES RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RUSSELL
Last Name:ZACHEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 ROCKSIDE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2155
Mailing Address - Country:US
Mailing Address - Phone:216-643-3114
Mailing Address - Fax:216-643-3011
Practice Address - Street 1:4110 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-7024
Practice Address - Country:US
Practice Address - Phone:216-491-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34001402Z208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH56031Medicaid
OH56031Medicaid
OHB99615Medicare UPIN