Provider Demographics
NPI:1629048913
Name:TATTERSALL, CHARLES W (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:TATTERSALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-528-4800
Practice Address - Street 1:8865 W 400 N STE 175
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9010
Practice Address - Country:US
Practice Address - Phone:219-877-2225
Practice Address - Fax:219-877-2230
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059210A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200487840Medicaid
E90021Medicare UPIN
IN217230NNMedicare ID - Type Unspecified