Provider Demographics
NPI:1235122094
Name:RADIS, CHARLES D (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:RADIS
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 1:51 SEWALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2643
Mailing Address - Country:US
Mailing Address - Phone:207-774-5761
Mailing Address - Fax:207-874-7478
Practice Address - Street 1:51 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2643
Practice Address - Country:US
Practice Address - Phone:207-774-5761
Practice Address - Fax:207-874-7478
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME110116560OtherPALMETTOG RAILROAD MEDICARE
ME0673610001OtherDMERC
ME115940199Medicaid
ME0673610001OtherDMERC
ME110116560OtherPALMETTOG RAILROAD MEDICARE