Provider Demographics
NPI:1548286362
Name:IVES, CHARLENE A (MD)
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:A
Last Name:IVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 ROUTE 146 STE 101
Mailing Address - Street 2:
Mailing Address - City:HALFMOON
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3239
Mailing Address - Country:US
Mailing Address - Phone:518-373-3924
Mailing Address - Fax:518-373-3808
Practice Address - Street 1:258 HOOSICK ST STE 206
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2450
Practice Address - Country:US
Practice Address - Phone:518-272-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010450207RH0003X
NY236239207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02671869Medicaid
VT1009057Medicaid
VTVN2958Medicare ID - Type Unspecified