Provider Demographics
NPI:1881818615
Name:LINE, CHARLES GENGHIS (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:GENGHIS
Last Name:LINE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6483 CITATION DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2994
Mailing Address - Country:US
Mailing Address - Phone:248-922-3074
Mailing Address - Fax:248-922-3081
Practice Address - Street 1:6483 CITATION DR
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2994
Practice Address - Country:US
Practice Address - Phone:248-922-3074
Practice Address - Fax:248-922-3081
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2011-12-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101241384207Q00000X
MI4301095854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1881818615Medicaid