Active NPI
Charles Theodorovich, CRNA
- Anesthesiology Physician
- Bingham Farms, MI
National Provider Identifier
1710945746
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Anesthesiology Physician
- License
- 4704101769
- Practice address
- 30200 Telegraph Rd
Suite 220
Bingham Farms, MI 48025-4502 - Phone
- (248) 258-5058
- NPI assigned
- May 1, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Anesthesiology Physician | 207L00000X | 4704101769 | MI | Primary |
Addresses
Primary practice location
30200 Telegraph Rd
Suite 220
Bingham Farms, MI 48025-4502
Mailing address
321 N Gordon St
Marshall, MI 49068-1214
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| P00309996 | Other | MI | RAILROAD MEDICARE |
| 104831359 | Medicaid | MI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Certified Registered Nurse
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Northstar Anesthesia of Michigan II PC | Anesthesiology | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Anesthesiology Physician
- Irving, TX
- NPI 1437268026
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1146441600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1396310400000",
"number": "1710945746",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "321 N GORDON ST",
"city": "MARSHALL",
"state": "MI",
"postal_code": "490681214"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "30200 TELEGRAPH RD",
"address_2": "SUITE 220",
"city": "BINGHAM FARMS",
"state": "MI",
"postal_code": "480254502",
"telephone_number": "248-258-5058"
}
],
"practiceLocations": [],
"basic": {
"last_name": "THEODOROVICH",
"first_name": "CHARLES",
"credential": "CRNA",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-01",
"last_updated": "2014-04-01",
"status": "A"
},
"taxonomies": [
{
"code": "207L00000X",
"taxonomy_group": "",
"desc": "Anesthesiology",
"state": "MI",
"license": "4704101769",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "P00309996",
"state": "MI"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "104831359",
"state": "MI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Bingham Farms, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.