Provider Demographics
NPI:1396742151
Name:CHARLES, PATRICK ANSELM (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:ANSELM
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 21158
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-0158
Mailing Address - Country:US
Mailing Address - Phone:313-640-1250
Mailing Address - Fax:313-640-1291
Practice Address - Street 1:18601 MACK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-3250
Practice Address - Country:US
Practice Address - Phone:313-640-1250
Practice Address - Fax:313-640-1291
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301058495207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108233132OtherBCBSM PROVIDER #
MI2876665Medicaid
MIF01802Medicare UPIN