Provider Demographics
NPI:1720064819
Name:TEGELER, CHARLES HERMAN IV (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HERMAN
Last Name:TEGELER
Suffix:IV
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-9016
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-9016
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC382212084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
48771OtherMEDCOST
5617OtherPARTNERS
130025126OtherRR MEDICARE
5009152OtherAETNA
VA6100805Medicaid
WV2006823000Medicaid
NC8982352Medicaid
82352OtherBCBS
SCQ38221Medicaid
5617OtherPARTNERS
NC8982352Medicaid