Provider Demographics
NPI:1861456220
Name:FENTON, CHARLES R (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:FENTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:893 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-9181
Practice Address - Country:US
Practice Address - Phone:616-252-3400
Practice Address - Fax:269-792-6268
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101011742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08-5-03-0006-4OtherBCBS PIN
MIG13813Medicare UPIN
MIM53750012Medicare PIN
MI1861456220Medicaid