Basic Information
Provider Information | |||||||||
NPI: | 1376583526 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TATE | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 27128 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841270128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4352512500 | ||||||||
FaxNumber: | 4356564907 | ||||||||
Practice Location | |||||||||
Address1: | 1380 E MEDICAL CENTER DR | ||||||||
Address2: | STE 1500 | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847902123 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4352512500 | ||||||||
FaxNumber: | 4356564907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2006 | ||||||||
LastUpdateDate: | 06/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 42885 | CO | N |   | Other Service Providers | Specialist |   | 207RC0001X | 42885 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | 42885 | CO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0001X | 7724231-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
ID | Type | State | Issuer | Description | 85581224 | 05 | CO |   | MEDICAID |