Provider Demographics
NPI:1235154212
Name:MCGLADE, CHARLES T (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:T
Last Name:MCGLADE
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 1:1200 GATEWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1176
Mailing Address - Country:US
Mailing Address - Phone:036-837-7305
Mailing Address - Fax:541-204-1997
Practice Address - Street 1:1200 GATEWAY LOOP
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1176
Practice Address - Country:US
Practice Address - Phone:036-837-7305
Practice Address - Fax:541-204-1997
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD154802085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8296675Medicaid
AKMD8960RMedicaid
OR210260Medicaid
AKMD8961RMedicaid
OR300029705Medicare PIN
ORP00383049Medicare PIN
AKMD8961RMedicaid
D72906Medicare UPIN
OR210260Medicaid
OR300032393Medicare PIN
OR00WCPGHFMedicare PIN
OR135709Medicare PIN