Provider Demographics
NPI:1992831960
Name:JESSUP, CHARLES E (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:JESSUP
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1003 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-1234
Mailing Address - Country:US
Mailing Address - Phone:989-892-7722
Mailing Address - Fax:989-892-7455
Practice Address - Street 1:125 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:MI
Practice Address - Zip Code:48756-5117
Practice Address - Country:US
Practice Address - Phone:989-873-3352
Practice Address - Fax:989-873-3949
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101005335208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI233873OtherRIVERBEND
MI010F510190OtherBUE CROSS
MI0156150214OtherBCBS
MI080Z910290OtherBLUE CROSS
MI4303974Medicaid
MI2624597Medicaid
MI383369085OtherCOMMERCIAL
MI4279897Medicaid
MI010Z900580OtherBCBS GROUP
MI233866OtherRIVERBEND
MI382821013OtherCOMMERCIAL
MI383369085100OtherCOMMUNITY CHOICE
MI0Z90058OtherBCBS GROUP
MI382821013OtherCOMMERCIAL
MI233866OtherRIVERBEND
MI2624597Medicaid
MI383369085100OtherCOMMUNITY CHOICE
MI233873OtherRIVERBEND
MI0Z90058OtherBCBS GROUP
MI080Z910290OtherBLUE CROSS
MIMI1566Medicare UPIN