Basic Information
| Provider Information | |||||||||
| NPI: | 1760484869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAROCHAK | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | IRENE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523243 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162527200 | ||||||||
| FaxNumber: | 6162526239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101010442 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OS13558 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | OS13558 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RN0300X | 5101010442 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RC0200X | 5101010442 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4846754 | 05 | MI | MEDICAID | AC010442 | 01 | MI | BCBSM | OTHER | 70-0-F32947-0 | 01 | MI | BCBS CPIN # | OTHER |