Provider Demographics
NPI:1548329220
Name:RICE, CHARLES WILLIAM (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:RICE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 BEAVER DR
Mailing Address - Street 2:BLD. D
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-2440
Mailing Address - Country:US
Mailing Address - Phone:814-371-6442
Mailing Address - Fax:814-371-4245
Practice Address - Street 1:90 BEAVER DR
Practice Address - Street 2:BLD. D
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2440
Practice Address - Country:US
Practice Address - Phone:814-371-6442
Practice Address - Fax:814-371-4245
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002358L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001397055Medicaid
PA5853210001OtherDME SUPPLIER #
PA001397055Medicaid
PA102980Medicare ID - Type Unspecified