Provider Demographics
NPI:1508163577
Name:LIEDER, CHARLES MARSHALL (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARSHALL
Last Name:LIEDER
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 1:5954 EAGLES WAY
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9762
Mailing Address - Country:US
Mailing Address - Phone:517-449-0059
Mailing Address - Fax:
Practice Address - Street 1:2850 S WABASH AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2491
Practice Address - Country:US
Practice Address - Phone:312-842-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136846207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136846Medicaid