Provider Demographics
NPI:1659351195
Name:WIRTZ, CHARLES E (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:WIRTZ
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 1:1501 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724-1257
Mailing Address - Country:US
Mailing Address - Phone:715-568-4650
Mailing Address - Fax:
Practice Address - Street 1:1501 THOMPSON ST
Practice Address - Street 2:
Practice Address - City:BLOOMER
Practice Address - State:WI
Practice Address - Zip Code:54724
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26899208M00000X
WI26889207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30698700Medicaid
WI30698700Medicaid
12075-0004Medicare ID - Type Unspecified