Provider Demographics
NPI:1881786853
Name:EMERY, CHARLES RICHARD
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:EMERY
Suffix:
Gender:M
Credentials:
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 1006
Mailing Address - Street 2:
Mailing Address - City:ROSEBUD
Mailing Address - State:SD
Mailing Address - Zip Code:57570-1006
Mailing Address - Country:US
Mailing Address - Phone:605-747-2231
Mailing Address - Fax:
Practice Address - Street 1:SOLDIER CREEK ROAD
Practice Address - Street 2:ROSEBUD IHS HOSPITAL
Practice Address - City:ROSEBUD
Practice Address - State:SD
Practice Address - Zip Code:57570-1006
Practice Address - Country:US
Practice Address - Phone:605-747-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant