Provider Demographics
NPI:1376502260
Name:RICHERT, CHARLES A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:RICHERT
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:PO BOX 3941
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-3941
Mailing Address - Country:US
Mailing Address - Phone:360-459-7770
Mailing Address - Fax:360-459-4361
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:PROVIDENCE ST PETER HOSPITAL
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5166
Practice Address - Country:US
Practice Address - Phone:360-491-9480
Practice Address - Fax:360-459-4361
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035845207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8222333Medicaid
8855830Medicare ID - Type Unspecified
G65615Medicare UPIN