Provider Demographics
NPI:1134117989
Name:BLEECHER, CHARLES G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:BLEECHER
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 1:243 BOYLE RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1954
Mailing Address - Country:US
Mailing Address - Phone:631-696-2000
Mailing Address - Fax:631-696-2003
Practice Address - Street 1:243 BOYLE RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1954
Practice Address - Country:US
Practice Address - Phone:631-696-2000
Practice Address - Fax:631-696-2003
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E87981Medicare UPIN
NY36F301Medicare ID - Type Unspecified