Basic Information
| Provider Information | |||||||||
| NPI: | 1033126743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAX | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | MURRAY | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3042 SHANNON LN | ||||||||
| Address2: | |||||||||
| City: | BAY CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487062318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896864886 | ||||||||
| FaxNumber: | 9896847334 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 WEISS ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486025251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 06/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 5901001030 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 5095000 | 01 | MI | BLUE CROSS/BLUE SHILED | OTHER | 2122755 | 05 | MI | MEDICAID |