Provider Demographics
NPI:1881611424
Name:RASMUSSEN, CHARLES MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:RASMUSSEN
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 1:1070 N CURTIS RD
Mailing Address - Street 2:STE 125
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1238
Mailing Address - Country:US
Mailing Address - Phone:208-377-1415
Mailing Address - Fax:208-375-3451
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:STE 2205
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6308
Practice Address - Country:US
Practice Address - Phone:208-884-0036
Practice Address - Fax:208-884-3805
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6484207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
59907OtherBLUE CROSS OF IDAHO
000010147672OtherREGENCE BLUE SHIELD OF ID
E57363Medicare UPIN
1130444Medicare ID - Type Unspecified