Basic Information
| Provider Information | |||||||||
| NPI: | 1982770160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREMAINE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LEO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 45TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463213927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199246544 | ||||||||
| FaxNumber: | 2199228502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 45TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463213927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199246544 | ||||||||
| FaxNumber: | 2199228502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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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 | 207XS0114X | 01035537A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100202530A | 05 | IN | MEDICAID |