1356386387 NPI number — CHARLES E ROLLISON DO

Table of content: CHARLES E ROLLISON DO (NPI 1356386387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356386387 NPI number — CHARLES E ROLLISON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLLISON
Provider First Name:
CHARLES
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356386387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 CAMPUS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANCOCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49930-1569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-483-1050
Provider Business Mailing Address Fax Number:
906-483-1270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 CAMPUS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
HANCOCK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49930-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-483-1050
Provider Business Practice Location Address Fax Number:
906-483-1270
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  5101012731 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: 92318 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 382626196 . This is a "TRICARE HEALTH NET" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4684825 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0P10950 . This is a "TRAVELERS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: H76548 . This is a "HEALTH ALLIANCE PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7662412 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0C16002133 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 382626196 . This is a "PPOM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0649513 . This is a "CIGNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0C16002 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 160B511630 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1652510814 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CR012731 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0999854 . This is a "HEALTH PLUS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4684825 . This is a "MOLINA HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CR012731 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 16814 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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