Provider Demographics
NPI:1346343969
Name:MCINNIS, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:MCINNIS
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 1:541 HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090
Mailing Address - Country:US
Mailing Address - Phone:781-326-1128
Mailing Address - Fax:781-326-1438
Practice Address - Street 1:541 HIGH STREET
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090
Practice Address - Country:US
Practice Address - Phone:781-326-1128
Practice Address - Fax:781-326-1438
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA56701207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3005038Medicaid
A58243Medicare UPIN
J05184Medicare ID - Type Unspecified