Basic Information
| Provider Information | |||||||||
| NPI: | 1982631198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CREECH | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873906 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 EXECUTIVE BLVD | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109014164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453579002 | ||||||||
| FaxNumber: | 8453680303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 219459 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02230730 | 05 | NY | MEDICAID |