Basic Information
| Provider Information | |||||||||
| NPI: | 1629024112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SETSER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ADAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36123 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347936140 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Practice Location | |||||||||
| Address1: | 7073 CLYO RD | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374355857 | ||||||||
| FaxNumber: | 9379124960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35- 07-6961 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 49624 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2239947 | 05 | OH | MEDICAID |