Provider Demographics
NPI:1831139740
Name:VANDER ROEST, CHARLES R (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:VANDER ROEST
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:PO BOX 634087
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:800-540-8739
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:28050 GRAND RIVER AVE
Practice Address - Street 2:ER DEPARTMENT
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5919
Practice Address - Country:US
Practice Address - Phone:248-471-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICV007456207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114570870Medicaid
MIMI1503Medicare PIN
MIMI1504Medicare PIN
MIMI1503016Medicare UPIN
MIMI1504016Medicare UPIN
MIN83060013Medicare ID - Type Unspecified
MI114570870Medicaid