Provider Demographics
NPI:1174675060
Name:SUTHERLAND, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:SUTHERLAND
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 1:1051 BOMAR CT
Mailing Address - Street 2:
Mailing Address - City:MARS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-3046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1051 BOMAR CT
Practice Address - Street 2:
Practice Address - City:MARS
Practice Address - State:PA
Practice Address - Zip Code:16046-3046
Practice Address - Country:US
Practice Address - Phone:724-687-0961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014225E207X00000X, 207X00000X
OH35070592207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHA12398Medicare UPIN
OHA12398Medicare UPIN