Provider Demographics
NPI:1124003389
Name:ROESEL, CHARLES MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:ROESEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MOLLER AVE
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-7142
Mailing Address - Country:US
Mailing Address - Phone:907-747-1722
Mailing Address - Fax:907-747-1755
Practice Address - Street 1:209 MOLLER AVE
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-7142
Practice Address - Country:US
Practice Address - Phone:907-747-1722
Practice Address - Fax:907-747-1755
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20793207Q00000X
AK3878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1575790Medicaid
OR0577260001Medicare NSC
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR930635514OtherMEDICARE TAX ID NUMBER
ORF92610Medicare UPIN
OR1407812365OtherNBMC GROUP NPI NUMBER
ORR130434Medicare PIN